Full text of "Nomination : hearing of the Committee on Labor and Human Resources, United States Senate, One Hundred Third Congress, first session, on M. Joycelyn Elders, of Arkansas, to be medical director ... Surgeon General of the Public Health Service, July 23, 1993"

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S. HRG. 103-628

NOMINATION

Y4.L 11/4: S. HRG. 103-628

Nonination, S.Hrg. 103-628, 103-1 H.

HEARING

OF THE

COMMITTEE ON

LABOR AND HUMAN RESOURCES

UNITED STATES SENATE

ONE HUNDRED THIRD CONGRESS
FIRST SESSION

M. JOYCELYN ELDERS, OF ARKANSAS, TO BE MEDICAL DIRECTOR IN
THE REGULAR CORPS OF THE PUBLIC HEALTH SERVICE, AND TO BE
SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE

JULY 23, 1993

Printed for the use of the Committee on Labor and Human Resources

U.S. GOVERNMENT PRINTING OFFICE
81-354 CC WASHINGTON : 1993

For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington. DC 20402
ISBN 0-16-044670-8

S. HRG. 103-628

NOMINATION

Y4.L 11/4: S. HRG. 103-628

Nonination, S.Hrg. 103-628, 103-1 H. . .

HEARING

OF THE

COMMITTEE ON

LABOR AND HUMAN RESOURCES

UNITED STATES SENATE

ONE HUNDRED THIRD CONGRESS
FIRST SESSION

M. JOYCELYN ELDERS, OF ARKANSAS, TO BE MEDICAL DD3ECTOR IN
THE REGULAR CORPS OF THE PUBLIC HEALTH SERVICE, AND TO BE
SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE

JULY 23, 1993

Printed for the use of the Committee on Labor and Human Resources

:c 1 3

U.S. GOVERNMENT PRINTING OFFICE
81-354 CC WASHINGTON : 1993

For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
ISBN 0-16-044670-8

COMMITTEE ON LABOR AND HUMAN RESOURCES

EDWARD M KENNEDY, Massachusetts, Chairman

CLAIBORNE PELL, Rhode Island NANCY LANDON KASSEBAUM, Kansas

HOWARD M. METZENBAUM, Ohio JAMES M JEFFORDS, Vermont

CHRISTOPHER J. DODD, Connecticut DAN COATS, Indiana

PAUL SIMON, Illinois JUDD GREGG, New Hampshire

TOM HARKLN, Iowa STROM THURMOND, South Carolina

BARBARA A. MIKULSKI, Maryland ORRIN G. HATCH, Utah

JEFF BLNGAMAN, New Mexico DAVE DURENBERGER, Minnesota

PAUL D. WELLSTONE, Minnesota

HARRIS WOFFORD, Pennsylvania

NICK Ltitlefieijd, Staff Director and Chief Counael
SUSAN K HATTAN, Minority Staff Director

01)

CONTENTS

STATEMENTS
Friday, July 23, 1993

Page

Elders, Dr. M. Joycelyn, nominated to be Medical Director in the Regular
Corps in the Public Health Service and Surgeon General in the Public

Health Service 6

Prepared statement 10

Hatfield, Hon. Mark 0., a US. Senator from the State of Oregon 13

Boren, Hon. David L., a UJS. Senator form the State of Oklahoma 15

Moseley-Braun, Hon. Carol, a UJ5. Senator from the State of Illinois 19

Prepared statement 19

Lambert, Hon. Blanche M., a Representative in Congress, from the State
of Arkansas 21

Kennedy, Hon. Edward M., a U.S. Senator from the State of Massachusetts,
prepared statement 25

Dodd, Hon. Christopher J., a US. Senator from the State of Connecticut,
prepared statement 45

Mikulski, Hon. Barbara A., a UJS. Senator from the State of Maryland,
prepared statement ~ 59

Wellstone, Hon. Paul D., a US. Senator from the State of Minnesota, pre-
pared statement 61

Wofford, Hon. Harris, a US. Senator from the State of Pennsylvania, pre-
pared statement 58

ADDITIONAL MATERIAL

Biographical sketch of Dr. Elders 85

Articles, publications, letters, etc 97

Responses of Dr. Elders to questions asked by:

Senator Coats 143

Senator Kassebaum 173

Senator Gregg 185

Senator Jeffords 193

Senator Kennedy 194

Senator Wellstone „ 195

OH)

NOMINATION

FRIDAY, JULY 23, 1993

U.S. Senate,
Committee on Labor and Human Resources,

Washington, DC.

The committee met, pursuant to notice, at 9:35 a.m., in room
SD-430, Dirksen Senate Office Building, Senator Edward M. Ken-
nedy (chairman of the committee) presiding.

Present: Senators Kennedy, Pell, Metzenbaum, Dodd, Simon, Mi-
kulski, Bingaman, Wellstone, Wofford, Kassebaum, Jeffords, Coats,
Gregg, and Durenberger.

Opening Statement of Senator Kennedy

The Chairman. The committee will come to order.

Welcome, Dr. Elders. We are delighted to have you here this
morning.

I want to explain both to the nominee and to the members of the
committee what the current situation is. We had scheduled this
hearing a week ago so that we might have the opportunity to con-
sider the nomination of Dr. Elders for the position of Surgeon Gen-
eral. Matters were then raised by members of the committee for
additional information, and we thought that was entirely appro-
priate, and Dr. Elders thought it was appropriate — certainly there
was information from the Comptroller of the Currency, technical
information that we should have.

We had rescheduled that hearing for today. During the period of
the past week, Dr. Elders has been attacked, I think viciously, and
she has been prepared to come here and respond to all questions —
not in a closed session as some have requested, but in an open ses-
sion.

I have been notified by the Majority Leader just a few moments
ago that there is an objection to this committee meeting beyond the
hour of 10. That has been filed. Under the Senate rules, for those
who are not familiar with them, there is the opportunity for any
single member of the Senate to object to a committee meeting once
the Senate has been in session for 2 hours, and we will have been
in session for 2 hours by 10 this morning.

That objection has been filed, so until the Senate recesses we will
not have the opportunity after 10 to permit Dr. Elders to respond
to many of the allegations, charges, distortions, misrepresentations
and character assassinations that have been directed at her.

These charges have been made by members of the Republican
Party — not by my distinguished ranking member, Senator Kasse-
baum, who has been nothing but cooperative and helpful to us in

(1)

gaining information and who has been positive in every possible
way. But the objection has been filed.

For the purposes of the members of this committee, I want to in-
dicate that whenever the Senate adjourns today — whenever it is —
this committee is going to be back in session, and we are going to
stay here all afternoon, we will stay here during the evening, and
we will come back tomorrow if necessary and stay as long as nec-
essary on Saturday. Over the time I have been in the U.S. Senate,
that has happened, at other times. It happened with the Americans
with Disabilities Act, when we met until 2 in the morning.

When you have an individual as distinguished as Dr. Elders, who
has been honored by the President of the United States by nomi-
nating her to a position of enormous importance to the American
people, when public health issues cry out for attention and leader-
ship, to have a parliamentary procedure used to deny the full op-
portunity for this committee to hold its examination of the wide
range of public policy issues involved and of the charges which
have been levelled against Dr. Elders — and when Dr. Elders is de-
nied the opportunity to present her case to the public — I think it
is a shame for this institution to have that kind of policy. But it
does exist, and quite frankly, we are going to deal with it in the
only way that we know how, and that is with fairness to the nomi-
nee.

So I would suggest to all of my colleagues on this committee that
they cancel whatever plans they might nave had through the after-
noon, through the evening and through tomorrow, because that is
the way that we are going to proceed on this committee. I am not
going to be part of an effort to put this over for another day or for
another week, to permit scurrilous accusations to be made against
this nominee without an opportunity for her to respond.

So I will yield to my friend and colleague Senator Kassebaum for
whatever comments she would like to make, and then prior to the
time that we have the vote, which I understand will be in 10 or
15-minutes, we would usually recognize our colleagues who are
here to present the nominee

Senator Kassebaum. Mr. Chairman, if I may suggest, I would
like to forego my opening comments so that we could hear from our
colleagues who are here to make introductory statements.

The Chairman. That's an excellent suggestion.

Senator Coats. Mr. Chairman.

The Chairman. Senator Coats.

Senator Coats. Mr. Chairman, just to respond very, very briefly,
I too think it is important that this hearing go forward, and I see
no reason personally to delay this hearing. Just for personal rea-
sons, I would just as soon go forward this morning, but I will
change my plans and be here because I think Dr. Elders deserves
her day in court — this isn't really courtr— but deserves her day in
the confirmation hearing.

But I think also it is fair to say that anyone who is nominated
to a post as important as this, there ought to be a full and fair and
objective, thorough discussion of issues that have been raised most-
ly by the media and not members of the Republican Party; ques-
tions that have been raised by outside groups as any outside group
raises questions about any nominee whether it is Republicans or

Democrats, or liberals or conservatives, or left or right. We would
not be doing our duty if we did not thoroughly deal with questions
that have a legitimate relationship to the position that any nomi-
nee is seeking. I think Dr. Elders would ask no less than the oppor-
tunity to address the questions that have been raised.

Are all those questions fair? I don't know. Dr. Elders will have
an opportunity to State her position on that. But they are legiti-
mate questions that the public has, and I think we have an obliga-
tion to explore those, and I intend to ask Dr. Elders a number of
those questions.

I don't know why it is necessary to delay the hearing. I do know
there has been concern which I have raised relative to some of the
financial records, because that goes to a question that has been de-
bated in the media. We were not able to secure all the necessary
financial documents from Dr. Elders relative to our examination of
that. I suggested that perhaps because she obviously has a right
not to disclose that — I think it would be helpful if she would, but
she has a right not to

The Chairman. Well, does the Senator have a question?

Senator Coats. Yes, this is all leading up to a question.

The Chairman. I want the record to show that the ranking mi-
nority member Senator Kassebaum urged that Dr. Elders be given
an opportunity to make a presentation, and that there are Senators
who are in the situation where on television they are raising ques-
tions, and under the Senate rules, Dr. Elders won't even have an
opportunity to make a presentation.

Senator Coats. Well, I regret that, Mr. Chairman

The Chairman. I regret it, too.

Senator Coats. — and I am not the one who raised that objection.
But I also object to the chairman saying that except for Senator
Kassebaum, Republicans have some conspiracy going here to trash
Dr. Elders. That is not true at all.

The Chairman. I didn't say

Senator Coats. You said the Republican Party has made vicious,
scurrilous accusations against Dr. Elders, and that is not true.
There is no partisan conspiracy to do that.

The Chairman. I said that the Republican Party member
objected

Senator Coats. You didn't say that.

The Chairman. Well, TO say it right now.

Senator Coats. I appreciate it.

The CHAIRMAN. It was very interesting. I am now violating my
own rule, but Fll take 1 minute. The member who objected called
me last night in my office at quarter of nine. He said he had some
additional questions. I said come on by — we had had a full day of
debate on national service, but come on by. He was on his way to
an engagement, some other previous engagement.

So I said, all right, send your staff by; Fll stay here, and well
work through the evening. He said, I don't know whether I can find
my staff. I said, Fll have my staff stay here; they know where they
can reach me. I am available all evening.

At 11:30, a member of the staff called my staff and said we have
some additional questions, and we want to put you on notice, and
the Senator put me on notice that he was going to object. And he

is a member of the Republican Party, and he is a member of the
Republican Policy Committee.

Now, if you want anything more, Senator, I would be glad to get
into it. I would hope that we would give Dr. Elders in the few mo-
ments that remain an opportunity which she has been denied so
far to be able to face this committee and face the U.S. Senate and
make what comments she wishes to make.

So if there is no

Senator Coats. Mr. Chairman, I promise you I won't take more
than 15 seconds to reply.

It sounds to me like your complaint is with a member of the Re-
publican Party and not with the Republican members of this com-
mittee. To my knowledge, there isn't a Republican member of this
committee who has objected to this hearing going forward this
morning.

The Chairman. Listen, Dan, I have been around here a long
time, and you might believe that — but unless anyone else would
like to

Senator Coats. Well, Mr. Chairman, I absolutely believe that,
and I think the record should not reflect otherwise.

Senator MlKULSKl. Mr. Chairman, could we hear from our distin-
guished African American scholar and, for once, begin to treat
women in Senate hearings with respect and dignity? Could we pro-
ceed? [Applause.]

The Chairman. I would just point out for the record that in the
time that I have been on this committee I have not seen denial of
an opportunity to hear a nominee under Republican or Democrat
Presidents alike until now.

I would recognize Senator Boren, Senator Hatfield, Senator
Moseley-Braun and Representative Lambert for 1 minute each; is
that okay?

Senator Boren. Could we come back and make our introductions
later? Wouldn't that be more appropriate?

The Chairman. I think it would be, if that's agreeable with you.
I'd like to try to give Dr. Elders a moment, and then when we re-
convene at the end of the session, give you an opportunity. I think
it would be very useful for the members to hear what our distin-
guished colleagues feel about it.

We are operating with about 10 minutes to go

Senator Hatfield. Mr. Chairman, may I comment?

The Chairman. Yes.

Senator Hatfield. Mr. Chairman, I will not be pressured on
time, and I believe with the honor I have here this morning that
I am not able to perform that in 1 minute. Therefore, I would be
happy to return at some later timeuuring the day.

I am a Republican, and I am proud to be here as a Republican
and as an American to have the high honor of introducing Dr. El-
ders. I was honored when she called me to ask me to fill in on this
situation because of Senator Pryor and Senator Bumpers having to
attend the funeral of Mr. Foster in Arkansas. But I just do not
think this important introduction can be handled in 1 minute, so
I would like to ask to be excused and return at a time when I have
the proper time.

The Chairman. The Senator is absolutely correct, and we would
be honored to hear your introduction later when we reconvene.

Senator Boren.

Senator Boren. Mr. Chairman, I feel the same way. Again, I was
very appreciative that Dr. Elders asked me to appear this morning,
and since Senator Pryor and Senator Bumpers were not able to be
here, I also bring a statement from Senator Pryor that I think is
eloquent testimony from one from her home State that should be
heard by members of this committee, and I hope to have an oppor-
tunity to add my own comments of support to that statement.

So I would be very willing. I think this is a very important mat-
ter, and I would be very willing to return at any time of the day
or night, with pride to be here, to help present Dr. Elders to this
committee.

So I also would like to have the opportunity to return later and
make introductory remarks.

The Chairman. Senator Moseley-Braun.

Senator Moseley-Braun. Thank you very much, Mr. Chairman.

I am not standing in for either Senator Bumpers or Senator
Pryor. I am here for me, and I am here because of my tremendous
respect for Dr. Elders.

I too look forward to the opportunity to make an introduction, to
contribute whatever I can contribute to this hearing, and I hope we
can go forward quickly, smoothly, thoroughly, and that this fine
woman be given the opportunity to be heard and voted out of this
committee.

The Chairman. Thank you.

Representative Lambert, we are delighted to have you here.

Ms. Lambert. Mr. Chairman, it is with a great deal of pleasure
and a great deal of pride that I have walked across the front of the
Capitol to come over here in support of a dear friend of mine and
someone who has produced tremendous results in my district in
eastern Arkansas.

I will devote the day, the evening. I do come from the other body,
and it is good to see that you all conduct in similar fashion and
that similar obstacles happen on this side. But I am here, I am
available, and I would like to spend a little more than 1 minute
in support of this tremendous person who has done so very much
for the State of Arkansas. So I am available all day, and into the
evening.

The CHAIRMAN. Wonderful. Thank you very much.

Senator Kassebaum.

Senator Kassebaum. Mr. Chairman, if we are not going to pro-
ceed, I was trying to expedite the procedure so there could be op-
portunity. But there now remain only 10 minutes, and I assume ev-
erybody is going to come back.

I would like to make two points. There are two Republicans on
this committee, Senator Durenberger and Senator Jeffords, who
have announced support for Dr. Elders. I think it is very mislead-
ing to categorize the Republicans as being in objection to Dr. El-
ders.

I was one who, along with you, Senator Kennedy, asked for the
financial records to be reviewed by the FBI that are held in con-

fidence by the Office of the Comptroller of the Currency. I think
this is important, and I discussed it with Dr. Elders.

It is, as you have said, Mr. Chairman, obviously a rule of the
Senate that anyone can raise an objection on the floor of the Senate
to holding a committee meeting 2 hours past the call of the Senate.
And that has been honored in every committee. So I think we
should not get into finger-pointing at this point.

I would like to say to my good friend Senator Mikulski that nei-
ther do I think it is a disservice to women. I think that we in our
committees really always have these opportunities, and we fre-
quently get into these controversies: I believe Dr. Koop's nomina-
tion was lield up for 9 months, so it really should not be taken for
more than it is. And while we might have wished we could have
proceeded ahead, we will at a later time.

The Chairman. I appreciate what the Senator says, but when we
are notified by the chairman of the Republican Policy Committee
at quarter of 10 at night of his intent to object, without his being
willing to come down and express what kind of concerns those are,
and evidently, the Republican leader is not prepared to be suffi-
ciently persuasive to have that kind of an objection recalled, Fll let
the record stand for itself.

Dr. Elders, please proceed.

STATEMENT OF DR. M. JOYCELYN ELDERS, NOMINATED TO BE
MEDICAL DIRECTOR IN THE REGULAR CORPS IN THE PUB-
LIC HEALTH SERVICE AND SURGEON GENERAL IN THE PUB-
LIC HEALTH SERVICE

Dr. Elders. Thank you, Senator Kennedy, Senator Kassebaum,
and members of the Senate Labor and Human Resources Commit-
tee. It is a great honor to appear before you today as President
Clinton's nominee for the position of Surgeon General.

I want to thank you for taking time from your busy schedules to
meet with me during the past few weeks. I appreciate and look for-
ward to a continuing relationship.

Before proceeding further, I realize you have a problem with
time, but I would like to take just a few minutes to thank my dear
husband, Oliver Elders, my brother, Reverend Chester Jones, my
friends, and all of our coworkers, and all of those, many of whom
are here today

The Chairman. Would you like to introduce them, Dr. Elders?

Dr. Elders. That's fine, Senator. I realize we are out of time.

The Chadxman. No; just introduce them. We're all right. We al-
ways have time for members of the family.

Dr. Elders. All right. My husband, Oliver Elders. [Applause.]
My brother, Reverend Chester Jones, his wife, and his mother-in-
law. [Applause.] And the person who has probably really done the
most for Joycelyn Elders the past 5Vz years at work, Ms. Willie
Mitchum, my secretary, who Keeps me on schedule. [Applause.]
And the chairman of our board of health, Dr. Miller. [Applause.]

The Chahiman. All right Senate rules discourage applause, but
we appreciate it very much.

Dr. Elders. Thank you, Senator, for that opportunity.

I thank them for the support they have given me for years, but
particularly the last few months and especially the last few days.

Many say that I am a lightning rod — that is the pin you see me
wearing today — but please, know that my thunder is behind me.

I appear before you today at a time when our entire Nation is
facing great challenges in health care. More than 37 million Ameri-
cans have no health insurance. AIDS, violence, teen pregnancv, a
drug-resistant strain of tuberculosis, low immunization rates all in-
dicate we have not done a very good job of protecting our Nation's
health.

We must focus on prevention to heal our Nation. Prevention re-
quires education. We cannot educate people who are not healthy,
and we can't keep them healthy if they aren't educated. I have
some personal ana professional understandings of these challenges,
and I would like to share them with you.

First, I am the oldest of eight children. I had never seen a physi-
cian prior to my first year in college. One of my earliest experiences
concerning the lack of health care was my 4-year-old brother, who
had a ruptured appendix and was taken to the doctor more than
10 miles away on the back of a mule. His abdomen was lanced, a
drain placed, and he was sent home.

I have heard my mother scream during difficult child deliveries
without any medical help. I have seen bright young people all over
this country in an ocean surrounded by the sharks of drugs, alco-
hol, homicide, suicide, AIDS and teen pregnancy, while we argue
over whose values we are going to teach.

Second, I know about taking advantage of opportunity. The Unit-
ed Methodist Church helped me reach the first rung of the ladder
that enabled me to be here today by providing me a scholarship to
Philander Smith College at age 15. After college, I enlisted in the
service. I attended medical school on the GI bill and, after complet-
ing medical training became a board-certified pediatric
endocrinologist. I know the importance of providing opportunities
for our children today.

My experience has led me to know first-hand many of the pro-
grams administered by the Public Health Service and other Fed-
eral agencies. I have been a provider of many of the services sup-
ported by public health programs, both as a physician in public
health clinics and at the University of Arkansas School of Medi-
cine.

Fourth, I have been a teacher and a professor on the University
of Arkansas faculty for more than 20 years.

During my medical career, I was a National Institutes of Health
career development awardee. I served on NIH study sections, advi-
sory committees for both the NIH and the FDA, and as a consult-
ant to many of the advisory committees for many of the programs
provided by the Public Health Service.

I am an experienced researcher, having authored many publica-
tions on hormonal growth disorders in cnildren. I appreciate the
need for scientific facts to back up conclusions.

For the past 5Vi years, I have been an administrator at the State
level as director of the Arkansas Department of Health. Last year,
I was honored by my fellow health directors when they elected me
president of the Association of State and Territorial Health Offi-
cers, after serving as secretary of the Association and a member of
the executive committee.

Finally, Senators, I am a coalition builder. While I was the direc-
tor of the Arkansas Department of Health, I used my time recruit-
ing the help of churches, schools, civic organizations, judges, busi-
nesses, and local communities to help me meet the needs of our
youth. I realized that we in public health could not do the job
alone. We needed to cooperate, communicate, collaborate, and form
partnerships if we wanted to take care of the problems we had.

We needed to use all of the resources available in our commu-
nity. Our United Methodist bishop had a statement that I fre-
quently borrowed from. He said it's like dancing with a bear. When
you are dancing with a bear, you can't get tired and sit down. You
have to wait until the bear gets tired, and then you sit down.

I do not believe that we can dictate from above what local com-
munities need to do to solve all of our public health problems we
are encountering today. We must empower each community to help
design its own solutions.

As a result of my background, education, training and experi-
ence, I have become a strong advocate for programs that will
strengthen families, reduce risky behaviors, improve health, and
enable children to become healthy, educated, motivated, and to
have hope for the future.

The Chairman. Dr. Elders, it is 10 a.m. and there has been an
objection filed under the Senate rules; it is my intention to con-
tinue long enough to allow you to complete your statement. The
only penalty, as I understand it, is that the chairman is liable for
the cost of the transcript, which I will be willing to do.

Senator MiKULSKi. Well all pitch in. Til have a bake sale.

The Chairman. So well allow you to complete your opening
statement and then recess.

Senator Coats. I think that's appropriate, Mr. Chairman.

The Chairman. It would be a disservice not to hear Dr. Elders

out.

Dr. Elders. Thank you, Mr. Chairman.

Far too many of our children are becoming members of what we
now call the "5-H Club"— every night in America, millions of chil-
dren go to bed hungry. Thirty-seven million of our Americans are
helpless; a third of those are children. Out of the thousands of peo-
ple who are homeless, a third of those are children. Too many are
nugless, with nobody to love them; many of them are hopeless, with
nowhere to go and no way to get there.

I would like now to explain what I am about, but before I do
that, I would like to address some of the issues about me that have
been raised in the past few days.

On the Social Security, it has been paid. My husband had power
of attorney for his mother, and he handled her affairs.

As to the salary issue, until last week, I had been taking vaca-
tion days, which I earned, and for which I would have been paid
anyway, to split my time between here and Arkansas. Once I real-
ized that I needed to be here full-time working on this confirmation
hearing and preparing for the office of Surgeon General, I resigned
as director of the Arkansas Department of Health.

As to the bank, any loans I received were well below the maxi-
mum limit; they were approved as required, and made at the going
rate of interest and have all been paid.

I will be happy to discuss these and other issues in greater detail
at the close of my statement.

We all know that children need multiple interventions, Senator.
Single strategies will not work. It is like having a leaky bucket
with ten holes, and we plug five, so we still have a bucket that is
leaking.

I am about early childhood education to help children get a good
start in life. Only 18 percent of Medicaid children in Arkansas, the
poorest of the poor, have an opportunity to attend Head Start. We
know that early childhood education is cost-effective and a preven-
tive measure that reduces the likelihood that such children will
end up as dropouts, pushouts, in prison, or as teen parents.

I am about — and have always been about — comprehensive health
education programs from kindergarten through 12th grade. Com-
prehensive health education means age-appropriate nealth edu-
cation programs which include information about self-esteem, alco-
hol and substance abuse, including tobacco; nutrition education and
fitness; violence prevention; AIDS and human sexuality. It means
being healthy and feeling good about yourself. Comprehensive
health education teaches children to take care of themselves. Our
children deserve that chance.

We must educate our parents so that they will know how to in-
still in their children the courage, strength, and perseverance to
meet the challenges of growing up. Because we do not want them
to do anything wrong, many times parents are unable to give their
children sound, solid direction.

I believe we need to teach our young men to be responsible. Chil-
dren born today need all the help they can get to succeed in this
world, including two nurturing parents. They deserve to know and
receive support from both parents.

I am about comprehensive school-based or school-linked health
services which provide primary preventive health care for children
in or near the schools, where they spend most of their time. In Ar-
kansas, it has been our policy that the local community decides if
they want a school-based clinic. They decide what they want in
their school-based clinics. And if you as a parent do not want your
children to use all of the services, or some services, you can select
the services that you want your children to use in that clinic.

I believe we must offer our bright young people hope for the fu-
ture by providing scholarships to those who stay out of trouble and
do well in school. It is far cheaper to pay to send them to college
than it is to send them to prison.

Finally, I am about improving the quality of life for all Ameri-
cans. We have improved the quantity or length of life; now we must
improve the quality of life by: preventing chronic and infectious dis-
eases; reducing infant mortality; eliminating the serious disparities
between minorities; preventing and reducing the toll of injuries and
disabilities in our society; preventing violence; improving women's
health, and providing care and services for our elderly so they can
live in dignity and comfort during their final days.

As Surgeon General, I will be a true advocate for the improve-
ment of health in America, a strong and dedicated leader for the
Public Health Service Commissioned Corps, and an effective rep-
resentative for the Public Health Service.

If confirmed, Senator Pell, I want you to know that I am excited
about commanding the Public Health Service Commissioned Corps.
What doctor wouldn't be excited about working with over 6,500
highly trained and experienced health professionals? The Commis-
sioned Corps plays such a key role in addressing the public health
threats of today, whether they be polio, AIDS, floods, or hurricanes.
I commit to you that under my leadership, the Corps will continue
to be a vital force in protecting the health of America.

Mr. Chairman and members of this committee, I want to change
the way we think about health by putting prevention first. I want
to challenge the behaviors and attitudes of Americans by promoting
programs and policies which will enable each of us to be respon-
sible for our own health. I want to be the voice and the vision of
the poor and the powerless. I want to change concern about social
problems that affect health into commitment. And I would like to
make every child born in America a planned and wanted child.

Should I be confirmed, I would like to work with each of you and
all America to develop an action plan to improve the health of our
country. To me, it is not enough just to reform the health care sys-
tem. We will never have a large enough budget to address all the
health care needs of our citizens if we do not start thinking preven-
tion and taking personal responsibility for our health.

I am a hard worker. I am willing to give my time and my talent.
We have a great task before us, and I hope you will see fit to make
me a part of your team.

I would like to close with an old Greek saying that I use a lot.
It says that a society grows great when old men plant trees under
whose shade they know theyll never sit. I look forward to working
with you to help plant trees for the future generation of America.

Thank you.

[The prepared statement of Dr. Elders follows:!

Prepared Statement of Dr. M. Joycelyn Elders

Good Morning. Mr. Chairman, Senator Kassebaum and members of the Senate
Labor and Human Resources Committee, it is a great honor to appear before you
today as President Clinton's nominee for the position of Surgeon General. I want
to thank you for taking time from your busy schedules to meet with me during the
past few weeks. I appreciate that opportunity and look forward to talking with those
of you I have not yet met.

Before proceeding further, I would like to take this opportunity to thank my dear
husband, Oliver Elders, and all of my family and friends, many of whom are here
today, who have supported me throughout my career, and particularly, for their sup-
port (luring the past 6 months. Many say I am a lightening rod. Please know that
they havebeen my thunder.

I appear before you today at a time when our entire Nation is facing great chal-
lenges in public health. AIDS, violence, teenage pregnancy, a drug resistant strain
of tuberculosis, low immunization rates all indicate we have not done a very good
iob at selling healthy lifestyles in this country. I believe the only way to heal our
Nation is through prevention. Prevention -requires education. If confirmed, I would
make my utmost goal the education of our people, all our people, on how to stay
healthy.

I have some personal and professional understanding of these challenges that I
would like to share with you.

I am the oldest of eight children. I had never seen a physician prior to my first
year at college. One of my earliest memories concerning the lack 01 health care was
my 4 year old brother, who had a ruptured appendix and was taken to the doctor
more than 10 miles away on the back of a mule. His abdomen was lanced, a drain
placed, and he was sent home. I have heard my mother scream during difficult child
deliveries, without any medical help. I have seen bright young people all over this

country surrounded by social problems impacting health such as drugs, alcohol, vio-
lence, homicide, suicide, AIDS and teenage pregnancy. My experience has led me
to know first hand many of the programs administered by the Public Health Service
and other Federal agencies.

Second, I know about taking advantage of opportunities. The United Methodist
Church helped me reach the first rung of the ladder that enabled me to be here
today by providing a scholarship to Philander Smith College at age 15. After college,
I enlisted in the Army and became a physical therapist. Following my service years,
I attended medical school on the GI bill and after completing my medical training
became a board certified pediatric endocrinologist. I know the importance of provid-
ing opportunities for our children today.

Third, as a physician in public health clinics and at the University of Arkansas
School of Medicine, I have been the provider of many of the services supported by
public health programs.

Fourth, I am a teacher. For over 20 years, I have been on the faculty in the De-
partment of Pediatrics at the University of Arkansas School of Medicine.

During my medical career, I was a National Institutes of Health career develop-
ment awardee. I served on NIH study sections, advisory committees for both the
NIH and the FDA and, as a consultant to or as a member of advisory committees
for many of the programs sponsored by the Public Health Service. I am an experi-
enced researcher having authored many articles on hormonal growth disorders in
children. I appreciate the need to have good scientific facts to back up conclusions.

For the past 5 Vi years, I have been an administrator at the State level as Director
of the Arkansas Department of Health. Last year, I was honored by my fellow
health directors when they elected me President of the Association of State and Ter-
ritorial Health Officers (ASTHO).

Finally, I am a coalition builder. Since becoming the Director of the Arkansas De-
partment of Health, I have spent a great deal of my time, recruiting the help of
churches, schools, civic organizations, judges, businesses and local communities. I
realized that I could not do the job alone. I needed to mobilize all of the resources
available in our communities to help save the most valuable resource we will ever
have, our human capital. I do not believe that we can dictate from above what local
communities need to do to solve the public health problems we are encountering
today. We must empower each community to design their own solutions.

As a result of my background, education, training, and experience, I have become
a strong advocate for programs that will strengthen families, reduce risky behaviors,
improve health and enable children to become healthy, educated, motivated and to
have hope for the future. Far too many of our children have become members of
what I call the 5-H Club— hungry, healthless, homeless, hugless, and hopeless.

I would like to explain what 1 am about. But before I do that, I would like to ad-
dress some issues about me that have been raised.

I am about early childhood education to help children get a good start in life. Only
18% of Medicaid children in Arkansas, the poorest of the poor, have the opportunity
to attend Headstart. We know that early childhood education is cost effective and
a preventive measure that reduces the likelihood that such children will end up as
drop-outs, push-outs in prison, or as teen parents.

I am about — and always have been about— comprehensive health education from
kindergarten through the twelfth grade. Comprehensive health education means
age-appropriate health education programs which include information on: self es-
teem, alcohol and substance abuse including tobacco nutrition education and fitness
exercise, violence prevention, ADDS and human sexuality. It means being healthy
and feeling good about yourself. Comprehensive health education teaches children
to take care of themselves. Our children deserve that chance.

I advocate educating our parents so that all will know how to instill in their chil-
dren the courage, strength and perseverance to meet the challenges of growing up.
We do not teach parents how to be good parents. Because they do not want to do

anything wrong, too often some parents simply do nothing when it comes to provid-
ing sound, solid direction and guidance for their children.

I believe we must teach our young men to be responsible. Children being born
today need all the help they can get to succeed in this world — including two nurtur-
ing parents when possible. They deserve to know and receive support from both par-
ents. Young men must learn that being a father is more than just donating a sperm.

I am about comprehensive school-based or school-linked health services which pro-
vide primary preventive care for children at or near where they spend most of their
day, m school. In Arkansas, it was my policy (which was later codified) that the
local community and the local elected school board would decide if they wanted a
clinic in their school and what services to be provided in the clinic. Only 4 out of
24 clinics in Arkansas offer contraceptives on site. Even in those clinics, the parents

must sign a release statement before their child can receive family planning coun-
seling and contraceptives from the clinic.

I believe we must offer our bright, young people hope for the future by providing
scholarships to those who stay out of trouble and do well in school so they can at-
tend college. It is far cheaper to send them to college than to send them to prison.
Finally, I am about improving the quality of life of all Americans by:
-preventing chronic and infectious diseases, including cancer, heart disease, hy-
pertension, tuberculosis, and AIDS;
-reducing infant morbidity and mortality;

-eliminating the serious disparities in health problems that minority groups ex-
perience;

•preventing and reducing the toll of injuries and disabilities in our society;
-preventing violence;
-improving womens' health; and

-providing care and services for our elderly so they can live in dignity and com-
fort during their final years.

As Surgeon General, I will be a true advocate for the improvement of health in
America, a strong dedicated leader for the U JS. Public Health Service Commissioned
Corps and an effective representative for the Public Health Service.

Mr. Chairman, and members of this committee, I want to change the way we
think about health — by putting prevention first. I want to change the behaviors and
attitudes of Americans by promoting programs and policies which will enable us to
be responsible for our own health. I want to be the voice and the vision for the poor
and the powerless. I want to change concern about social problems that affect health
into commitment. And, I would like to make' every child born in America a planned,
wanted child.

Should I be confirmed, I would like to work with you and all America to develop
an action plan to improve the health of our country. To me, it is not enough to just
reform the health care system. We will never have a large enough budget to address
all the health care needs of our citizens if we do not start thinking prevention and
taking personal responsibility for our health.

I am a hard worker. I am willing to give my time and my talent. We have a big
task before us, and I hope you will see fit to make me part of your team.

I will be most happy to respond to any questions.

The Chairman. The committee will stand in recess subject to call
of the chair. As I mentioned earlier, we will meet when the Senate
is out of session and continue this hearing, today, this afternoon,
tonight, tomorrow, until it is concluded.

The committee stands in recess.

[Whereupon, at 10:10 a.m., the committee was adjourned subject
to call of the chair.]

[Whereupon, at 1:05 p.m., the committee reconvened, Senator
Edward M. Kennedy, chairman of the committee, presiding.]

The Chairman. Well come to order.

We'd be delighted to now recognize our friend and colleague, Sen-
ator Hatfield, for whatever presentation he would like to make.
Senator Boren is on his way, and Senator Carol Moseley-Braun is
on her way, as well as Congresswoman Lambert. So what well do
is hear the opening comments and then go to 15-minute rounds for
questioning, with my understanding with Senator Kassebaum that
whatever opening comments members wish to make will be in-
cluded in their time allocation so that we can move more rapidly
toward the questions and answers of the nominee. We have done
that on other occasions when we have been pressed in terms of
time considerations, although as far as the Chair is concerned, he
is not pressed for time. But we shall proceed in that particular
way.

So we thank our colleagues very much, as well as the nominee.
We apologize for any inconveniences to her, and we also express
our appreciation to our fellow colleagues for their attendance here

and their willingness to share with us their views about the nomi-
nee, and well recognize them in order of seniority.
Senator Hatfield , we are glad to have you back.

STATEMENT OF THE HONORABLE MARE O. HATFIELD, A U.S.
SENATOR FROM THE STATE OF OREGON

Senator Hatfield. Thank you, Mr. Chairman and members of
the committee.

As I indicated earlier today, I come here today with ambivalence
of emotion. First, I am saddened that the ones who would normally
be making this introduction, Senator Bumpers and Senator Pryor
of Arkansas, are in Arkansas today attending the funeral of Mr.
Foster, who tragically ended his life. So that makes me sad that
I am here on that basis in part.

But I am very honored, and I am very happy to be here following
a telephone conversation with Dr. Elders, inviting me to make a
part of the introduction to this committee. I am especially honored
because, after listening to her opening statement this morning, she
really needs no introduction, because the eloquence of that state-
ment speaks for itself. But the Lord had to have an introducer in
John the Baptist, so I guess even as great as Dr. Elders is, it is
still appropriate to have an introducer.

Mr. Chairman, Dr. Elders has such a well-established record as
a medical professor, a pediatrician, a researcher and a teacher that
one cannot help but be moved by her biography and her back-
ground. Her achievements speak for themselves, and the committee
has had a presentation in printed form and in her eloquent state-
ment today, so I shall not go through those major accomplishments
again.

But I would like to say that in those accomplishments, Dr. Elders
is the embodiment and the living example that the American
dream is still a reality; that with will and determination and the
support of loving family and friends, that she can achieve and be-
come a tremendous verification of the American dream.

I suppose I feel very strongly about that for many reasons, in
that my privilege of chairing an Inaugural ceremony and sitting
there on that occasion with the President-elect and the outgoing
President and the Vice Presidents, the Members of Congress, mem-
bers of the Diplomatic Corps, the U.S. Supreme Court, and thou-
sands of cheering Americans, I turned to my wife, and I said, "Not
bad for the son of a railroad blacksmith and the daughter of an im-
migrant longshoreman."

She responded quickly to me: "Only in America."

So I cannot help but make some identification with the fact that
this is a possible upwardly mobile society.

Dr. Elders first was brought to my attention by my daughter
Elizabeth, who last month graduated from the Oregon Health
Science University as a medical doctor and was telling me about
her commencement speaker, Dr. Elders, for whom there had been
given a standing ovation by the students and faculty of the Oregon
Health Science University.

Also, probably one of the most distinguished, I believe, of medical
administrators, Dr. Peter Kohler of the Oregon Health Science Uni-
versity, gave me a briefing on Dr. Elders because he had been at

the Arkansas Medical Center with Dr. Elders. So I do not come as
a stranger, even though I only met Dr. Elders herself day before
yesterday.

I also had the visitation of about a dozen of the presidents of the
American Association of Medical Colleges call upon me to give me
a further briefing and statements of support on behalf of Dr. El-
ders.

But then the lady herself appeared in my office only day before
yesterday. Dr. Elders is a spreader of virus. She infected me imme-
diately with a virus of enthusiasm, a virus of vision, a virus of hope
that she has for so many in this country. So I can say that I did
immediately become one of her short-time but long-term supporters
and enthusiasts.

Now, Mr. Chairman, Dr. Elders and I do not agree on abortion.
And some of my colleagues and some of my friends have had dif-
ficulty on that particular issue because they too disagree with Dr.
Elders. But as I look around this committee, I'm not sure I find
anybody who agrees with me on that position, so it looks like, Dr.
Elders, you win the vote on that basis. [Laughter.]

But let me say that Dr. Elders and I thoroughly agree, whole-
heartedly agree, and we have a strong lifetime commitment to pre-
vention and education to make abortion a moot issue. And if we
can lower our voices from all sides in this very volatile debate and
debated issue, I am convinced that the way we achieve that kind
of prevention and that kind of strategy to make abortion a moot
issue is guaranteeing that safe and effective contraceptives are
available and that individuals, especially teenagers, have been pro-
vided with enough education on sexual reproduction that they fully
understand the responsibilities that come with the choices they
make.

Certainly abstinence is preferred and should be stressed as a top
priority. But I want to emphasize again, this need not be an issue
in any way to disqualify Dr. Elders from acting as Surgeon General
when her commitment, like all of us, I believe, is to eliminate the
issue by prevention and education.

Other issues on which Dr. Elders and I have agreement include
access to primary care for all Americans and also, the expansion
of medical research and education. Mr. Chairman, members of the
committee, I am concerned that even in our debates at the moment
on comprehensive health care, there has been an absence of the
major mechanism for ultimate cost control, and that is medical re-
search and our commitment to medical research. But she is very
catholic in her perspective in that she sees the totality of this kind
of health goal for America — delivery, education, access, research.
And it is a part of a whole and cannot be segmented from reality.

I am also convinced that with her leadership, her spirit and her
intelligence, she will be a great Surgeon General.

So again, Mr. Chairman, I will say it is an honor to be here and
to assist my colleagues, Senator Boren, Senator Moseley-Braun and
others in presenting Dr. Elders to this committee. I wish her well,
and I look forward to the privilege of casting a vote on the floor
of the U.S. Senate on her confirmation.

The Chairman. Thank you very much for those excellent com-
ments, and we are very grateful to you, Senator Hatfield, for your
presence.

Senator Boren.

STATEMENT OF THE HONORABLE DAVID L. BOREN, A U.S.
SENATOR FROM THE STATE OF OKLAHOMA

Senator Boren. Thank you very much, Mr. Chairman.

It is very difficult to find words that would add to those words
that have been spoken by Senator Hatfield and that were spoken
so eloquently this morning in our abbreviated session by Dr. Elders
herself. . o

I very much appreciate the opportunity to join with Senator Hat-
field and other colleagues in presenting Dr. Elders to you as the
President's nominee For Surgeon General. I have watched as a
neighbor across the border from Arkansas her career, her record,
ana I have admired her courage. As I was listening to her this
morning, I was reflecting not only about Dr. Elders but about the
State of American politics. The qualities we most need in this coun-
try are forthrightness, honesty, the moral courage of speaking
clearly one's convictions straight from the heart, and a deep and
abiding caring about the people.

As I listened to Dr. Elders this morning, I heard and I felt and
I sensed those qualities in her presentation. One of the tragedies
of American politics and the age in which we are all participating
in it is that it is becoming increasingly difficult to be allowed to
perform public service in our country today when one does speak
forthrightiy and honestly, when one's public statements are an ac-
curate transcript of one s feelings and best judgments about what
is in the public interest. It has become easier for those with no
record ana no opinions, those who avoid controversies, those who
do not have the moral courage of their own convictions, those who
have never engaged in any controversy because they have never
taken a stand on anything, to be easily and speedily put into posi-
tions of public trust in our country than it is for those who are
most needed because they talk straight to us and honestly to us
about our responsibilities.

It is also a sad thing that in our politics in the day and time in
which we are living that we have come to stop at times focusing
upon the fair treatment of individuals, the fair valuation of their
careers, their records, and even their points of view, and we tend
instead sometimes, because of our strong feelings on one issue or
another, to make people pawns in a political chess game and to
treat them as such instead of treating them as human beings who
are entitled to be evaluated on the Basis of their own character,
record, and pronouncements.

So I was honored when Dr. Elders called me and asked me to
come. I can only tell you that I am even more honored to be here
after hearing her remarks this morning, and I come with an even
stronger conviction that she should be the next Surgeon General of
the United States for the sake of our country and especially for the
sake of the children in our country.

My good friend from Arkansas, Senator Pryor, asked me to rep-
resent him today. He and Senator Bumpers, as Senator Hatfield

said, both very much wanted to be here. They feel very strongly
about this nomination, but because of the tragedy that took place,
they are in Arkansas attending the funeral services of their close
friend today.

Senator Pryor before he left did write in his own handwriting on
a legal pad some comments, and as always, and since Senator
Pryor knows Dr. Elders so well, his comments are so much to the
point, and I would hope that the chairman might indulge me in
reading at least a portion of what Senator Pryor wanted to say to
you if he were here today.

He says: "In America, every 32 seconds, a teenage girl becomes
pregnant Every 35 seconds, a child is born into poverty. Every 64
seconds, an infant is born to a teenage mother. Every 14 minutes,
an infant dies in the first year of its life. In 1965, 10 percent of
all children under 18 lived in a single-parent home. In 1985, that
number had risen to 21 percent. Mr. Chairman, these are not facts
and figures that apply to Bulgaria or Uganda; they apply to Amer-
ica— our America — and it is happening today."

"A bold and clear voice has been heard that awakens us. It
shakes us. It makes us talk and think about the unthinkable con-
sequences to our families, our communities, our country and our so-
cial fabric should we continue to ignore the enslaving cycles of
events that eat away at America's family structure. That clear
voice belongs to Dr. Joycelyn Elders, who is today President Clin-
ton's nominee."

"Dr. Elders knows poverty because she lived in poverty, and she
fought her way out. Sne is a controversial person because she prac-
tices in a controversial world of reality and human misery. She
makes hard statements because she wants us to listen. She wants
us to listen because the stakes are so high, and to fail would be
so devastating."

"Out of this tough world of reality, Dr. Elders has developed
strong beliefs. She sees a society in deep trouble, and she offers so-
lutions to problems that people do not like to talk about. She says
what she thinks, and what she says is what she believes. With Dr.
Elders, there is no sugar coating, no abstract mumblings. For us,
she is the brave person who hears the time bomb ticking and has
the boldness to say that time is running out. That is courage. That
is conviction. And, Mr. Chairman, that is leadership, the kind of
leadership America needs to face down the crisis that challenges
our families, our communities and our society."

Senator Pryor closes by saying: "I proudly support and endorse
Dr. Joycelyn Elders for the post of Surgeon General. I am confident
she will challenge all of us to face up to the tough problems, to
reach for realistic solutions, and to help America be the best that
we can be." -

I subscribe to all of those comments, those direct and forceful
comments from our friend and our colleague, Senator Pryor, and I
would like to add a few thoughts of my own.

I first became aware of the exemplary work of Dr. Elders, as I
said, several years ago, living in our neighboring State. Several
years later I had an opportunity, just by chance, to turn on the tel-
evision one night and see a documentary about her work in Arkan-
sas.

As I began to learn more about Dr. Elders and her ideas, I real-
ized that whether or not one agrees with every, single suggested
solution that she has offered for the public health problems of our
country, no one can dispute her absolute commitment to helping
people, particularly children and young^ people.

Later, as a trustee of Yale University, I had the opportunity to
see Dr. Elders receive an honorary degree from my alma mater.
The description of this outstanding American from her honorary
degree citation, which I might say was drawn by those who are
eminent in the health field and the faculty of the university, elo-
quently sums up Dr. Elders and her philosophy about public
health. Here is what the citation said, as she was presented that
honorary degree: "As a physician, scientist, educator and public of-
ficial, you have brought new advocacy and commitment to the
health of the public. Because of your vision, creativity and courage,
Arkansas legislators have confronted the issues of teenage preg-
nancy in the context of community health. While others debate na-
tional health insurance, you advocate the principles of access, qual-
ity and cost-effectiveness. For many of your colleagues dedicated to
maternal and child health, you are the Nation's leader."

And we have heard the selection that she has received from
those who head the public health programs of the various States
and municipalities of this country; they feel the same, and they
have selected her as their leader.

I have been personally impressed by the personal achievements
of Dr. Elders that Senator Pryor^s statement has detailed— raised
by sharecropper parents in rural Arkansas, one of eight children.
In college, she scrubbed dormitory bathrooms to raise money for ex-
penses. She was the first African American woman to graduate
from the University of Arkansas Medical School. She has Deen ac-
claimed by health officials and organizations across this country as
an extraordinary pediatrician and an exemplary public health offi-
cial and a groundbreaking researcher in the study of child develop-
ment. She was the first African American and the first woman to
hold the position of director of the health department in Arkansas.

Her nomination has been endorsed by over 150 medical associa-
tions. As the committee can see, her personal background and med-
ical credentials are outstanding.

However, much of the debate about Dr. Elders' nomination has
been waged not on the basis of her qualifications, not on the basis
of her character, but on the basis of some distortions of her views
on public health issues. Unfortunately, people who speak frankly
about our Nation's problems, as I said, who confront the real crises
without rose-colored glasses, often become controversial. And she
has spoken very frankly.

We need, Mr. Chairman and members of the committee, someone
like Dr. Elders, who is not afraid to point out our Nation's prob-
lems in all of their stark, ugly, and difficult reality.

In many ways, the importance of the post of Surgeon General
stems from its ability to serve as the bully pulpit. It is not a doc-
tor's job to mince words. It is the physician's job to tell us what is
wrong in the plainest possible terms. And in her position as direc-
tor of the health department in Arkansas, Dr. Elders, if she had
minimized in that position the problems, if she had acted like a

politician in the worst sense of that term, if she had not pointed
out what needed to be said, she would most likely sail through the
nomination process without controversy. But if she had done that,
she would not have done her job, and as Surgeon General, I think
all of us expect her to continue to tell us what is wrong with our
public health in the plainest possible terms.

To say a nominee is unfit because she speaks bluntly and plainly
about issues related to public health and the social fabric of this
country could not be more dangerous. We must allow and encour-
age our public health officials to speak frankly, as Dr. Elders has
demonstrated. She reminds me of another outspoken advocate of
public health, our former Surgeon General and an appointee of
President Reagan, Dr. C. Everett Koop.

Dr. Elders' views have been misunderstood primarily because her
critics have forgotten her clear and frequently expressed commit-
ment— and she made it again, Mr. Chairman, in her statement this
morning, and she made it very strongly — her frequently expressed
commitment to local control of comprehensive health and edu-
cational services. She supports bringing health services to where
young people spend most of their time — to the schools. However,
she advocates with equal force local control by the school board of
the services that will be offered. She has never sought to impose
solutions or views on others; instead, she has tried to educate and
reach consensus.

For example, Dr. Elders helped establish school-based clinics in
Arkansas, but allowed local school boards and clinics to determine
the services they should offer according to their needs, and in fact
to allow parents to determine, as she said this morning, the serv-
ices the individual child would receive. Solutions to health prob-
lems in neighborhood with few intact family units and racked by
violence and drug abuse may not be the same solutions that are
appropriate to different kinds of neighborhoods. Local control al-
lows parents and communities to solve health problems in ways de-
signed to fit their particular environment and to best serve the
needs of children.

Addressing the health crisis of our Nation will not be an easy
task. The statistics have already been given in Senator Pryor's
statement. I would also point out that almost 70 percent of all indi-
viduals who have been incarcerated in this country over the past
several decades were born out of wedlock. We may differ as to the
best solution to these problems, but we cannot afford to turn away
from the fact that these problems exist. We must not bury our
heads in the sand. Dr. Elders challenges us to confront these prob-
lems. As Surgeon General, she can effectively play that role.

I strongly encourage the committee to carefully and positively
evaluate her nomination. The life and the career of Joycelyn Elders
sends a message to young people across America, and I hope young
people across America were listening to Joycelyn Elders today as
she testified. She sends the message that no matter how modest
may be your financial means, no matter what your race or your
gender, through ability, hard work, and above all, though a good
heart and commitment to help others, you can make a difference
in your home community, your State, and your Nation.

I urge this committee to give Dr. Elders an opportunity to make
that major impact on our country.

The Chairman. Thank you very much, Senator Boren. We are
very appreciative of your presence and obviously very sincere and
eloquent comments.

We now recognize Senator Moseley-Braun. We are glad to have
you here today.

STATEMENT OF THE HONORABLE CAROL MOSELEY-BRAUN, A
U.S. SENATOR FROM THE STATE OF ILLINOIS

Senator Moseley-Braun. Thank you very much, Mr. Chairman,
ladies and gentlemen of the committee.

I have a formal written statement that I had been prepared ear-
lier today to deliver. However, I don't think it would be possible to
add to the words that Senator Boren just shared with this commit-
tee. He has described Dr. Elders' record. He has described her ap-
proach to public service. And quite frankly, the description that he
nas made is such that I genuinely would like to associate myself
with Senator Boren's remarks.

I was delighted the other day, in fact, when I spoke on the floor
in support of Dr. Elders' nomination, that almost impromptu, Sen-
ator Boren joined in the colloquy — and it became a colloquy be-
cause he joined in — and we engaged in dialogue on the floor of the
Senate about this fine nominee and the importance of this nomina-
tion. .

And so, having associated myself with Senator Boren's remarks,
I would ask first that my written statement be received for the
record, and then I would like to add a few words of my own regard-
ing both this nominee and the significance in my mind of her nomi-
nation.

The Chairman. The statement will be printed in the record as
if read.

[The prepared statement of Senator Moseley-Braun follows:]

Prepared Statement of Senator Moseley-Braun

Mr. Chairman, I am pleased to be here today to introduce Dr. Joycelyn Elders
to the committee. I have known Dr. Elders personally for only a short while, but
I have known of her outstanding reputation in the field of public health for a long,
long time.

Dr. Elders will make a superb Surgeon General of the United States. She has,
throughout her career, demonstrated her intelligence, her sound judgement, her
character and her integrity. And I am impressed by her candor, her courage, and
her dedication to improving the health of all of the citizens of the State of Arkansas.
It is impossible to speak with her and not recognize her warmth, and how much
she cares about improving the health of every American.

Dr. Elders has demonstrated a longstanding commitment to the health of chil-
dren. She was a pioneer in preventive health care, and has always stressed early,
aggressive intervention. In addition, her tenure as director of health for the State
oiArkansas, has been marked by great achievements. During her term, the State
nearly doubled the number of children receiving immunizations, and the number of
pregnant women and children receiving food assistance. Further, she was instru-
mental in luring a significant number of physicians to rural community health cen-
ters so that those areas would no longer be under-served.

Dr. Elders has worked hard to improve and expand prenatal care, early childhood
screening, HTV prevention, and cancer prevention programs for the citizens of Ar-
kansas. Prior to becoming the director of health, Dr. Eiders established a successful
clinical practice and research career in pediatric endocrinology at the University of
Arkansas.

Dr. Elders specializes in the arena of reality education. She is not afraid to speak
eloquently and candidly about sex to our young people, or about other critical public
health issues. This type of candor was revered in former Surgeon General C. Everett
Hoop, and I believe Dr. Elders deserves the same dignity ana respect.

Dr. Elders is superbly qualified for the job of Surgeon General. Her entire career
from academics to clinical practice to administration has prepared her well for the
new challenges that will, I hope, come before her as Surgeon General. I won't be-
labor the point — her credentials speak for themselves.

I endorse the candidacy of Dr. Elders for U.S. Surgeon General wholeheartedly
and without reservation, and I am proud to be able to be with her here today.

Senator Moseley-Braun. Thank you.

The nominee comes highly recommended and highly qualified for
this position. Dr. Elders nas a record of excellence both personally
and professionally. All of her years, she has demonstrated the will-
ingness and ability to reach outside of herself from the early days
of ner career; from the early days, even before she was a physician,
she was helping other people. And it seems to me again, following
on Senator Boren's suggestions, that that is precisely the kind of
person that we would want to encourage into public service.

Her dedication and commitment to excellence and hard work is
demonstrated by how far she has come. There is an old expression
that you can't really judge somebody until you have walked a mile
in their moccasins; but the fact is, the moccasins that Dr. Elders
has walked in should give inspiration to all of us that in this land,
in this country, opportunity really can be a reality for those who
are willing to hold onto hope and who are willing to work for and
pursue that opportunity, oo her own story, what might be de-
scribed as a Horatio Alger story, should be a source of inspiration
for all of us as Americans.

The importance of her nomination really is revealed more in the
statistics and the stories that the members of this committee know
all too well. Senator Boren touched on some of them. They are sta-
tistics that tell us the State of our public health in America. They
are statistics that tell us that we have a higher infant mortality
rate than many Third World countries — I wont name any, but cer-
tainly there are many of them that have more impressive statistics,
more impressive records of dealing with childbirth and early child-
hood than we have in this country. They are statistics that tell us
that single parenthood and teenage pregnancies are on the rise and
that our young people no longer seem to be able to connect to the
information that is even there for them. They are statistics that
tell us that we have in some parts of our country not only a lack
of health care services, but no health care services at all.

This is the greatest country, and it is inexcusable for us to have
health care in the State in which we presently find ourselves. Dr.
Elders has a record, Dr. Elders has points of view, she has specific
proposals with regard to addressing all of these issues, and ad-
dressing these issues in an honest way. And it seems to me that
in light of her qualifications for office, in light of the fact that we
have such a crisis in this country now in our public health, that
we would do ourselves very well indeed by confirming this nomi-
nee, giving her an opportunity to take on the challenge of being the
next Surgeon General of the United States.

Sitting here and listening to Senator Boren, I couldn't help but
think, and after having gone through what was not an undifficult
week in the Senate, how we talk an awful lot in Government and

here in Washington about change, and if anything, change has be-
come a watchword for a lot of different things. But I think if any-
thing at all, I perceive almost a sea change in our politics, and that
the change that was promised, the change that has been discussed,
really is in its own very difficult way — and I say "difficult" to Dr.
Elders because I know this process has not been easy for her — but
in a sometimes difficult and painful way, that change really is hap-
pening, and it is happening before our very eyes. And it may some-
times not be obvious and may not present itself right away, but it
is happening, and it is happening because people have decided to
make their Government responsive, and their Government is re-
sponding.

As Americans, that is something that I think we all need to cele-
brate, if we just take a moment to recognize that it is going on. Dr.
Elders represents the kind of positive change that we need to rec-
ognize, we need to support, we need to celebrate in our country,
and I am very honored to be a part of this nomination process; I
am very honored to speak in behalf of her nomination and to en-
courage the members of the committee to recognize the high qual-
ity and caliber of this nomination and of this nominee, the impor-
tance and significance of the confirmation vote that you are about
to undertake, and encourage you to proceed with great dispatch to
confirm Joycelyn Elders as the next Surgeon General of the United
States.

Thank you.

The Chairman. Thank you very much, Senator Moseley-Braun.
We very much appreciate your presence here and your willingness
to share those comments with us. We are grateful to you for taking
the time to be here.

Congress woman Lambert, we welcome your willingness to come
over here and share your thoughts and to make a second trip as
well. We are delighted to hear from you.

STATEMENT OF THE HONORABLE BLANCHE M. LAMBERT, A
U5. REPRESENTATIVE FROM THE STATE OF ARKANSAS

Ms. LAMBERT. Thank you, Mr. Chairman, and thank you to the
members of the committee for allowing me to cross the Capitol and
to come over and speak in support of my friend, Dr. Joycelyn El-
ders. I would also like to thank the chairman for his diligence in
getting through with this hearing and getting it before us today.

It is my distinct honor to be here today to introduce to you Dr.
Joycelyn Elders, President Clinton's nominee for U.S. Surgeon Gen-
eral, and I do believe I come to you from probably a different ave-
nue along with Senator Pryor and Senator Bumpers. I have direct
results of the efforts of Dr. Elders in my district, and Fd like to talk
about that a little bit today, if I may..

I would like to ask the committee here, as you begin our Nation's
quest for someone who can tackle our health care woes, I would
like to encourage you to focus on confirming a physician who has
produced results.

Back in Arkansas where Dr. Elders and I come from, my father
has always impressed upon me that hard work and results are
what count. A sixth-generation farmer, my father has said that
theories on crop disease and genetic engineering are impressive,

but if you don't have a rice crop in September to harvest, you really
haven't done your job as a farmer.

Likewise, our country needs someone like Dr. Elders, who offers
our Nation both technical theories and results. I would like to point
out a few of Dr. Elders' successes for which we in Arkansas are
very grateful.

As Arkansas' director of the department of health, Dr. Elders led
a tireless campaign for preventive health care, which we all know
and understand is the key to healthy people and a sound economy.
A true believer in educating folks about the health of their bodies
and their minds, Dr. Elders took her campaign to the people,
through the media and our schools, and she captured my deepest
admiration by looking for resource at hand and utilizing them,
rather than seeking to create new programs and more layers of bu-
reaucracy.

She showed the many support agencies how to dovetail together;
how they could work together in harmony and share resources to
accomplish even more results. A prime example of this can be seen
in Crittenden County in my district, where Dr. Elders encouraged
groups like The Children's Advocacy, the East Arkansas Legal
Services, the Families First Group, the Literacy Council, and the
county health department to share information and resources. This
enhanced their services and enabled them to reach a wider array
of people. It also fostered the attitude that a healthy mind and
body should go together to create a healthy contributor to society.

Within 3 years, Dr. Elders nearly doubled Arkansas' immuniza-
tion rate for 2-year-olds, from 34 percent to 60 percent. Her innova-
tive approach included encouraging after-hours clinics, introducing
simultaneous injections, and guaranteeing that every child who vis-
ited a health clinic received the shots he or she needed.

Dr. Elders then implemented a statewide computerized network,
similar to the model being proposed on the national level, that
tracks children for age-appropriate immunization status. Under the
direction of Dr. Elders, the number of early childhood screenings
grew 1,000 percent, from 4,000 to over 45,000. These screenings in-
cluded physical exams, vaccinations, vision and hearing screening,
and parental education. I am sure you have all talked to teachers
who have told you that correcting a youngster's vision and hearing
improves his or her classroom participation at a phenomenal rate.

Dr. Elders also joined First Lady Hillary Rodham Clinton to com-
bat infant mortality. Together, they developed the Arkansas Cam-
paign for Healthier Babies. Under that campaign, the maternity
caseload increased 17 percent between 1990 and 1992, and that
caseload continues to rise as pregnant women get the prenatal care
that they need. We have seen that an increase in prenatal care pro-
duces healthier, happier babies and costs less in the long run.

Dr. Elders' program achieved these tremendous results by in-
creasing clinic hours again, revising the health education classes,
and starting a toll-free phone number for women's health facts and
referrals.

On yet another preventive health care front, Dr. Elders expanded
cancer screening services for women. These services included mam-
mograms for low-income women, Pap smears for cervical cancer

screening, and follow-up for cervical cancer screening in all public
health clinics in Arkansas.

To fulfill her goal of educating our young people about health,
Dr. Elders instituted school-based clinics. We have heard a little bit
about those already and the ability of the local school districts and
school boards to maintain what was to be provided. The news from
the 12 clinics in my eastern Arkansas district tell a success story
of health care for people who may have had no other option. Nurses
at the clinic have told me they see students with concerns ranging
from headaches to flu symptoms and depression to thoughts of sui-
cide.

In Forest City High School alone, nurses have seen 50 students
a day. Nurses at one of the east Arkansas clinics, in a town that
has absolutely no other health care facility, discovered a heart
murmur when giving a child a pre-sports physical. In another in-
stance, they noticed a red streaked cut on a child's arm that re-
vealed blood poisoning. And when a teacher reported that a student
with cerebral palsy was acting abnormally in class and had not
walked in months, the nurse recognized signs of a brain hemor-
rhage. The student was treated and is now walking again.

These examples represent results. By promoting these school-
based clinics, Dr. Elders has brought health care into towns that
had no other option, and by bringing clinics to the schools, she has
helped to educate students and their parents.

In Arkansas, we have seen the health benefits of preventive care,
and we know there are financial benefits as well. We know that for
every dollar spent on preventive health care through immunization
and other measures, $10 is saved down the line. In Arkansas, Dr.
Elders has been a pioneer in proving these benefits of preventive
health care. She has proven that an investment in preventive care
provides a better quality of life as well as a better family, State
and Federal health care budget

In closing, let me reiterate that we need a Surgeon General who,
number one, recognizes the problems in our society's health; sec-
ond, sets goals to fulfill those needs; but most importantly, number
three, she gets results. We must have a result-oriented physician
at the forefront of our Nation's attempt to lower health care costs
through preventive medicine and education.

I offer for your examination additional editorial columns from
writers in my region who have endorsed Dr. Elders based on the
fact that they have seen the results of her health care leadership.

As you listen to the testimony of those who are assembled before
you, please keep in mind that hemorrhaging child that I mentioned
earlier whose life may have been saved by a school nurse. Please
remember that our State's immunization rate nearly doubled under
Dr. Elders' leadership. Base your decision on your own health care
goals for our Nation, and vote to confirm a woman who can fulfill
your goals and the goals of our Nation.

I respectfully encourage each of you, the distinguished members
of this Senate committee and the rest of the Senate, to speedily
confirm Dr. Elders and let her begin sharing the expertise she has
developed in Arkansas with the rest of the Nation.

I thank you for the time to be here.

The Chairman. Thank you very much, Congresswoman Lambert.
Those were enormously useful and helpful comments, to have the
kind of detailed examination of what a nominee has done in a prac-
tical way in the State. Generally speaking, we have presenters who
talk about either what they know about a nominee and the nomi-
nee's positive qualities but your comments and explicit details
about what Dr. Elders has meant to the young and the old in your
district are very welcome commentary and very helpful. It adds ad-
ditional credibility, obviously, to the nominee when she talks about
these matters because it demonstrates that she has hands-on
esperience with them.

Ms. Lambert. Thank you. Results do truly count.

The Chairman. We thank you very, very much. We appreciate
your appearance.

As I mentioned before, the way we intend to proceed is that well
have 15-minute rounds, and colleagues may use that time to make
a comment. I will make a brief comment and then go to question-
ing, and we'll alternate back and forth between Democrat and Re-
publican, and we'll permit those who have not had a round to have
a round before going to following rounds. Fll instruct staff to keep
the time.

The Surgeon General is the Nation's chief physician and one of
the principal leaders in the important effort to improve the quality
of care for all American people. Few positions in the Government
are more challenging; few offer greater opportunity to improve the
lives of so many Americans.

Every American child deserves a healthy start in life, but too
many children are denied that.

Countless older Americans also find themselves without the
health care or long-term care that they deserve. Improving wom-
en's health is a pressing need. Breast cancer strikes one in eight
American women at some point in their lives, but far too lew
women receive early detection and treatment. A third of all Amer-
ican women do not receive the basic preventive care they need. And
in all areas of health care, it is the poor and minorities who suffer
the most.

Self-inflicted wounds continue to plague the Nation. Smoking,
substance abuse, unhealthy lifestyles threaten million of our fellow
citizens and cost our society hundreds of billions of dollars each
year in health costs and lost productivity.

These challenges are extremely difficult, and an active, commit-
ted and dedicated Surgeon General can make a significant dif-
ference. Dr. Joycelyn Elders is superbly qualified to tackle the en-
tire range of health care challenges, especially the problems faced
by the Nation's children.

Dr. Elders' own life is a courageous story of her rise from poverty
to a career of healing and serving others. In her years at the Ar-
kansas Department of Health, she almost doubled the proportion
of children receiving timely vaccinations. She launched an assault
on infant mortality. She increased by 10-fold the number of poor
children receiving comprehensive health screenings. She dramati-
cally expanded cancer detection and treatment services for women.
She increased home care opportunities for senior citizens. She led
a crusade against the blight of teenage pregnancy. Most of all, she

waged an unceasing battle to bring good health care to all the chil-
dren of Arkansas.

In recent weeks, critics have come forward who disagree with po-
sitions she has taken. They have also circulated allegations regard-
ing her financial and business practices. Many of these allegations
have already been answered, and I know she is fully prepared to
address all of them today.

Dr. Elders brings a record of accomplishment and commitment to
this position that few can match. I look forward to her testimony
today and to her prompt confirmation. She is superbly qualified to
be Surgeon General, and the administration and the Nation are
fortunate to have her services.

[The prepared statement of Senator Kennedy follows:]

Prepared Statement of Senator Kennedy

The committee meets this morning to consider the nomination of
Dr. Joycelyn Elders of Arkansas to be Surgeon General of the Unit-
ed States. The Surgeon General is the Nation's chief physician and
one of the principal leaders in the important effort to improve the
quality of health care for all the American people.

Few positions in the Government are more challenging, and few
offer a greater opportunity to improve the lives of so many Ameri-
cans. Disease knows no boundary of age, race, gender, or class.

Every American child deserves a healthy start in life, but too
many children are denied that. Twenty nations have a better
record than the United States in preventing infant mortality. More
than half of all American children do not even receive timely basic
childhood immunizations.

Too many children are denied a fair chance for a healthy, fulfill-
ing life. Drugs, crime, and violence destroy the lives and shatter
the dreams of young Americans. The epidemic of teen-age preg-
nancy blights tne hopes and the future of hundreds of thousands
of children every year.

Countless olaer Americans also find themselves without the
health care or long term care they deserve. Senior citizens are
forced into nursing nomes because the care that would enable them
to remain in their own homes is not available or accessible. Too
often, for Americans of all ages, the lack of appropriate medical
care and the lack of preventive care results in premature death or
unnecessary disability.

Improving women's health is also a pressing need. Breast cancer
strikes one in eight American women at some point in their lives,
but far too few women receive early detection and treatment. A
third of all American women do not receive the basic preventive
care they need. For too long, medical research has shortchanged
them by failing to give adequate priority to women's diseases, and
by falsely assuming that research oh other diseases conducted on
men is applicable to women.

And in all areas of health care, it is the poor and minorities who
suffer the most.

Epidemics also present serious health care challenges. AIDS
threatens almost every American family — and the only cure is pre-
vention. An old killer — tuberculosis — has emerged from decades of
neglect as a renewed threat to public health.

Self-inflicted wounds continue to plague the Nation. Smoking,
substance abuse, and unhealthy life-styles threaten millions of our
fellow citizens and cost our society hundreds of billions of dollars
each year in health costs and lost productivity.

These challenges are extremely difficult, and an active, commit-
ted, and dedicated Surgeon General can make a significant dif-
ference. In the lQetfs, Surgeon General Luther Terry awakened a
generation to the dangers of smoking. In the 1980's, Surgeon Gen-
eral C. Everett Koop educated the Nation on the danger of AIDS.
And in the 1990's, Dr. Joycelyn Elders is superbly qualified to tack-
le the entire range of health care challenges — especially the prob-
lems faced by the Nation's children.

Dr. Elders' own life is a courageous story of her rise from poverty
to a career of healing and serving others. As a pediatric
endocrinologist and professor at the University of Arkansas Medi-
cal School, she was a respected clinician and medical researcher,
with more than 150 published scientific papers to her credit. In 6
years as the leader of the Arkansas Department of Health, she
earned a national reputation as a public health leader with an ex-
cellent record of accomplishment.

In her years at the Arkansas Department of Health, she almost
doubled the proportion of children receiving timely vaccinations.
She launched an assault on infant mortality. She increased by ten-
fold the number of poor children receiving comprehensive health
screenings. She dramatically expanded cancer detection and treat-
ment services for women. She increased home care opportunities
for senior citizens. She led a crusade against the blight of teenage
pregnancy. Most of all, she waged an unceasing battle to bring
good health care to all the children of Arkansas.

Because of her outstanding contributions to the health of the peo-
ple of Arkansas, Dr. Elders has been honored by the American
Medical Association, the National Governors Association, the Na-
tional Education Association, and many other organizations. She
has received honorary degrees from seven universities. She has
been chosen by her peers— chief health officers throughout the
country — to be the president of the Association of State and Terri-
torial Health Officers.

I am including in the record the list of organizations endorsing
Dr. Elders and a sample of the letters of support.

In recent weeks, critics have come forward who disagree with po-
sitions she has taken. They have also circulated allegations regard-
ing her financial and business practices. Many of the allegations
have already been answered, and I know she is fully prepared to
address them today.

Senator Kassebaum. Mr. Chairman, could I interrupt for just a
moment, please?

The Chairman. Yes.

Senator Kassebaum. Senator Jeffords has to leave in about 10
minutes to catch a plane. Would you mind yielding to him to make
some comments before he leaves?

The Chairman. I'd be delighted to yield.

Senator Jeffords. Thank you, Mr. Chairman.

First of all, Dr. Elders, it is good to be with you again. I had a
very excellent conversation with you last week. I did join Senator
Kassebaum in asking that this hearing be deferred so that we
hopefiilly would have sufficient information to relieve us of the bur-
den of examining some of the charges on ethics and other matters.

I have reviewed the information which has been provided to me,
and I find that I am satisfied that the only questions remaining are
of competence for service rather than ethical or legal questions. In
fact, I have no doubt about your competence at tnis time, either,
and I am pleased to mention that.

I would like to ask, though, a couple of questions in rather sen-
sitive and critical areas for which you have received criticism. First
of all, the question as to the effectiveness of your work with respect
to teenage pregnancies. We have received facts and information in-
dicating that notwithstanding your efforts, there was an increase
in teenage pregnancies, therefore raising questions as to the credi-
bility of the claims made by your supporters that you have an effec-
tive program in teenage pregnancy.

Would you respond to that, please?

Dr. Elders. Yes, sir. Thank you, Senator Jeffords. I would like
to respond to that. I, like probably most people in America, we are
all ashamed that the United States has the highest teenage preg-
nancy rate in the industrialized world. And I am not very proud
that Arkansas has the second highest in the United States.

Since I have been health director, we have seen the teenage
pregnancy rate rise 18 percent in the United States. In Arkansas,
it has risen at almost the same rate; in Arkansas, it has risen
about 17 percent. If you look at our 15- to 17-year-olds, it has in-
creased 11 percent over the 2 years that it was looked at, and it
increased in the United States approximately 18 percent.

I am not bragging. I am not proud about that. You see, we have
not had in Arkansas a comprehensive health education program
from kindergarten through 12th grade. We would have to start it,
and it would take, I think, 12 years to really say that we had true
results.

We have 24 school-based clinics in Arkansas. We have 1,200
school districts. And if everyone's record were perfect, I suspect it
would not make an impact.

In one of the schools where we had a 39 percent pregnancy rate,
I want you to know in that school, this was initiated by die presi-
dent of the school board, who is a banker's wife. They have a
school-based clinic, and it is one of the clinics that dispenses con-
traceptives. They nave one of the lowest teenage pregnancy rates
in any of the counties around. That was a northwest Arkansas, pre-
dominantly white, district.

We received a Federal grant, and it was called "Better Health for
Rural Teens,' 1997-plus percent black, 90-plus percent of the teen-
agers were on free lunch, so obviously, low income levels. Senator,
we were very proud that in 3 years, we went from a 57 percent

teenage pregnancy rate to the fact that in 3 years in this school,
they did not have a pregnancy, they did not have an abortion, and
they did not have a dropout.

So in that sense — but you know, we are talking about isolated
schools now — but as I said, it is very difficult for 24 schools to im-
pact the statistics of a whole State. So I am not proud of my record,
but I do feel that I have increased the awareness of the citizens of
Arkansas. I feel they are committed to working with their children,
and I feel that in that community that I talked about, there was
a commitment from the church, there was a commitment from the
school, there was a commitment from the health department, and
there was a commitment to make a difference for their children.
That is why I feel that we have to have commitment from every-
body in the community. The magic is not the clinic. In that clinic,
we probably have one of the best school health nurses in this coun-
try, as far as I am concerned — she is certainly one of the best in
Arkansas — and she has been here to testify, and she is just won-
derful. But it is that kind of a relationship that must be developed
with our children. The magic is not putting a building up over
there and saying there is the clinic. The magic is for all of us to
make a commitment to the most valuable resource we'll ever
have — our children.

Senator Jeffords. Thank you. That is an excellent response.

I would now like to ask you about another very controversial
statement which you made in this same area. I come from a rural
State, and we do not see many of the problems which are seen else-
where in this country. But I did serve as a shore patrol officer in
the Navy and also as a part of congressional hearings on teenage
prostitution in Los Angeles, and thus I am a little less shocked at
what goes in this country than some of my people at home.

This has to do with the utilization of the Norplant contraceptive
with respect to the prostitutes. It obviously is an extremely sen-
sitive area because of its relationship to abortion, but if you could
explain so that someone in Vermont might understand, why you
would feel it necessary to utilize the Norplant for prostitutes who
are drug addicts, and why that versus teaching safe sex and those
kinds of things are not possible.

Dr. Elders. Yes, Senator. Thanks for asking me that. I was
asked on a TV show would I support Norplant for a drug-abusing
woman, someone who was drug-addicted and was a prostitute. And
my answer was that I would very much support Norplant for that
woman so that she would not become pregnant and have a drug-
addicted baby.

And Senator, obviously what I would most like is one, that she
not be addicted; second, I would certainly like for her not to have
to use sex to get money to buy drugs. I would like for us to have
treatment centers for these women. But sometimes we don't have
that. We do have the availability of Norplant, but many of these
women, Senator, cannot afford Norplant. So what we do is we don't
offer them Norplant; they get pregnant, they have another baby
that is often drug-addicted and many times, premature. And I feel
that if we could have made available all the services that we had,
we could give her an opportunity to get into treatment, to get

cured, and then I would like for her to have as many babies as she
would like.

Senator Jeffords. Thank you.

Thank you, Mr. Chairman.

The Chairman. Thank you very much, Senator Jeffords. We ap-
preciate your questions.

Senator Kassebaum and I submitted questions to Dr. Elders per-
taining to her tenure as director of the board of the National Bank
of Arkansas, and she has responded. And, Dr. Elders, at least I am
going to get into the four or five areas that have been raised since
the time of your nomination, and then go back to some of the public
health issues, which I am most eager to hear you out further on.

Dr. Elders has responded in writing to those questions. In addi-
tion, the FBI was directed to conduct an independent review of the
relevant Comptroller of the Currency documents, which are not
publicly available. Senator Kassebaum and I have been briefed by
the FBI, and after careful review of the matter, Senator Kasse-
baum and I believe that Dr. Elders' answers are truthful, and that
they accurately reflect the findings of the FBI. Senator Kassebaum
and I would like to emphasize that we have checked with the FBI
and the Office of the Comptroller of the Currency, and we can con-
firm that Dr. Elders is not the target of any further investigation.

Now I'd like to go through these questions. You have written to
myself and Senator Kassebaum, with responses to our questions,
and we will make the letter part of the record, but I think it is im-
portant to hear you out on those particular questions.

[The letter referred to may be found in the appendix.]

The Chairman. Question number one: Was the National Bank of
Arkansas, NBA, ever subject to a formal enforcement action under
12 U.S.C., Section 1818?

Dr. ELDERS. The National Bank of Arkansas was subject to a for-
mal enforcement action under 12 U.S.C., Section 1818, in the form
of a formal written agreement between the Comptroller of the Cur-
rency and the board of directors of the bank.

The Chairman. Did an officer of the Comptroller of the Currency
in the OCC examination report find that any directors of NBA en-
gaged in practices that violated national banking laws regarding ei-
ther safety and soundness, or criminal activity?

Dr. Elders. I was briefed at board meetings on the content of
examinations reported by the OCC and the president of the board.
I was advised that all directors were cited in the examination re-
port as having violated national banking laws and safety and
soundness laws relating to their failure to supervise bank manage-
ment I was advised that the examination report did not find their
activities to be criminal.

The Chairman. Did any of the directors of NBA, including your-
self, receive letters of reprimand from the OCC?

Dr. Elders. I received a letter of reprimand solely in my capacity
as a member of the board of directors of the NBA. I believe that
Other directors who served on the board also received letters of rep-
rimand.

The Chairman. Well, that is my understanding that all the other
members did. Now, I also understand, Dr. Elders, that there was
some consideration of assessing civil penalties against the board of

directors' members by the Comptroller of the Currency. However,
it is clear that the final decision was. merely to give the directors
a warning in the form of a reprimand and impose no civil fines.

I just want to make the point that the decision to impose only
a reprimand was made by a committee of senior bank supervision
personnel who were all career employees of OCC; that the commit-
tee made a recommendation which resulted in a letter sent by the
director of bank supervision, himself a career employee of the OCC.
The decision was made prior to the installation of the new Comp-
troller of the Currency under the Clinton administration. Is that
your understanding?

Dr. Eldebs. Yes, that is my understanding.

The Chairman. Was any of your conduct cited specifically in any
examination report?

Dr. Elders. I believe that no conduct in which I personally en-
gaged was ever cited specifically in any examination report.

The Chairman. And were the directors ever informed by examin-
ers that the bank management was engaging or had engaged in
unsafe and unsound banking activities or violations of national
banking laws?

Dr. ELDERS. As a result of the examination report, board direc-
tors were informed that bank management had engaged in unsafe
and unsound banking practices which were in violation of national
banking law.

The Chairman. And did the directors take action to reasonably
ensure the activities cited in the OCC reports would not continue?

Dr. Elders. I believe that although the examiners acknowledged
that remedial actions were taken, the examiners did not view those
actions as sufficient to correct activities of bank management. Thus
a letter of reprimand was issued by the OCC to me and other direc-
tors.

The Chairman. Are you the target of any further investigation?

Dr. Elders. I believe that I am not the target of any further in-
vestigation.

The Chairman. We have made independent inquiry, and you are
not a target.

Did the board grant each director a $200,000 extension of credit?

Dr. Elders. The minutes of the board of directors' meeting indi-
cated that the directors were given an extension of credit up to
$230,000. This extension of credit was not construed by me as auto-
matic loan approval in that each loan was subject to the usual
banking policies and procedures applied for by anyone else. I ab-
stained from the board vote granting me the extension of credit.

The Chadjman. So you did take advantage of it. but as I under-
stand from your answer, the requirements tor the loan were the ex-
isting procedures and practices that existed in the bank?

Dr. Elders. That is correct, Senator. As I understood it, even
now, rather than an extension of credit, we thought it was a lend-
ing cap over which no director could borrow more than that be-
cause of the size of our bank, and if we were ever to have a loan,
it had to be subject to the same scrutiny, probably even more scru-
tiny, than anyone else.

The Chad*man. If the directors received such an extension of
credit, was this decision ever cited or criticized by bank examiners?

Dr. Elders. No, sir.

The Chairman. Did you ever borrow money from the NBA during
the time you were a member of the board?

Dr. Elders. Yes, sir.

The Chairman. What was the purpose of such loans?

Dr. Elders. I borrowed from the bank on various occasions
under terms and conditions available to all borrowers. The purpose
of the loans was primarily for commercial ventures, including the
purchase of real estate.

The Chairman. Did you ever borrow any money from the bank
at preferential rates not offered to other borrowers during the time
you were a member of the board?

Dr. Elders. No, sir.

The Chairman. Did you recuse yourself from discussion or ap-
proval by the board of any loan that you had requested?

Dr. Elders. I recused myself from voting on the extension of
credit by the other members of the board of directors to myself.

The Chadjman. Does the Comptroller of the Currency have to ap-
prove or sign off on any settlement agreement involving litigation
alleging allegations of Federal banking laws?

Dr. Elders. Not to my knowledge, no.

The CHAIRMAN. OK. My time has expired. In the next round, I
will go into both the Social Security issues and the "double-dip" sal-
ary issues in some detail. Maybe there are members who want to
ask some questions about that

Senator Dodd. Mr. Chairman, how long would that take? How
much time are you talking about?

The Chairman. Probably another 15 minutes.

Senator Dodd. Well, I would recommend, unless my colleagues
object, that you go through the questions now. The questions have
been raised. I mink going through them is worthwhile, and it
should be done with some sort of continuity.

Senator Wellstone. Mr. Chairman.

The Chadiman. Senator Wellstone.

Senator Wellstone. I think that certainly makes sense to me.
I would like to say that I have to leave a little earlier this after-
noon because of the crop damage in Minnesota, but it would be fine
with me if you went on with those questions.

Senator Kassebaum. Well, Mr. Chairman, let me say — and I
think Senator Durenberger has some of the same problems, and he
will have to leave — I would suggest that some of us can stay later,
and we can go back through those questions.

Senator Mikulski. I volunteer to stay later.

Senator Kassebaum. And 111 be here later.

The Chadiman. Td be glad, therefore, at least with the under-
standing on this side, that when the time comes back to this side,
if you want to yield, Fll just finish those particular items, and then
when that time is expired, return to the other side.

Senator Kassebaum. So you are going on now?

The Chairman. No. I am going to recognize you for 15 minutes,
and then when you have concluded, 111 take 15 minutes over here
and continue on these issues. Generally speaking, what we have
done in the past is, on those matters which are of general interest
to both the Republicans and the Democrats, go through those mat-

32.

ters in some detail first and then divide up the time in terms of
the policy questions. But we want to try to be scrupulously bal-
anced to the extent that we can in the remainder of these matters.

So I now recognize Senator Kassebaum.

Senator Kassebaum. Thank you, Mr. Chairman.

Dr. Elders, welcome. As Surgeon General, the role really calls for
the Surgeon General to be the recognized spokesman for the Na-
tion's health and to put forward an agenda for the public on the
priorities of health care and public health. In many ways, you are
the Nation's top doctor.

I would suggest that it calls forth for you an opportunity to ad-
dress those issues that you have already spoken to that you be-
lieve— and I think we would all believe — have great importance.
Also, I think it requires a responsibility to bring a consensus of
support together for those initiatives in addressing the concerns
that you would have as the Surgeon General.

Certainly, as has been mentioned, your dedication and your per-
severance in obtaining an education and all that you strived to get
that, keeping that goal in sight, must be an inspiring lesson to all
students. I think that is something that is important to young peo-
ple today, to recognize that goals can be achieved and that it does
require a certain amount or dedication and perseverance on the
part of everyone.

I would like to explore some questions with you, but first just to
ask — as Senator Jeffords asked — about the teenage pregnancy rate
in Arkansas. I think we are all concerned about the tragedy of
teenage pregnancy, younger people and their health, and the pov-
erty and lack of education that go with thatr— but you and I are
about the same age. We were in nigh school in the forties, and it
was not a major issue then. I, frankly, would never have thought
of anyone discussing condoms in the high school. It would have
been beyond my imagining and my parents'.

What do you think has caused the difference today?

Dr. Elders. Senator, I think there are perhaps several factors
that have influenced the difference. First of all, teenage pregnancy
has really been with us forever

Senator Kassebaum. But not in any way in the numbers that it
is today.

Dr. Elders. Well, one of the things is that there were more teen-
age marriages years ago, so there were fewer unmarried — they
were just far more likely to get married. So that is one thing.

The other thing, Senator, is that children are going into puberty
earlier. The average age of puberty, let's say, years ago, was 17;
100 years ago, it was 17 years. And it has been dropping about 4
months every 10 years.

Another factor that I feel has influenced teenage pregnancy. Sen-
ator, is television. Everything is on television. The other thing is
that there are more women who work. We think that approxi-
mately 70 percent of our teenage pregnancies occur between 3 and
5 in the afternoon after our children have gotten home.

So I feel that all of those are factors which are contributing. The
other thing that is a problem is that our children are growing poor-
er, and we know that children who are poor are three times more
likely to become teenage parents. In the 1970's, one in seven of our

children was poor, and we know now it is one in five. And in the
South, Senator, it is one in four. And when we look at our minority
children, it is one in two. So that is a real problem.

Senator Kassebaum. It is a real problem. I know that. I was just
curious from the experiences in the time frame in which we grew
up, because my guess is that also, your family, your parents were
making sure that you were either working or going to school.

Dr. Elders. Well, Senator, we had no choice.

Senator Kassebaum. Well, but that's a major difference today,
don't you agree?

Dr. Elders. Oh, yes; oh, yes, ma'am. I do not disagree with that.
Our children had jobs. We were busy. We were involved in many
other things. This is why I feel that we have got to start looking
at ways to involve our young people, our youth, in activities to get
them off the street so that they are not doing other things. We are
kind of leaving them out there for the drug kingpins, and to get
involved with alcohol and many other things, and it is very fright-
ening to me for our bright young people in Arkansas, Senator — in
this whole country. But I see them.

Senator Kassebaum. Is it true that — I have understood that the
role, perhaps, for the Surgeon General may be changed, and that
there is going to be a coordination of activities across the entire
Public Health Service? In your role, will you also try to prevent un-
necessary duplication of efforts across the Public Health Service?

Dr. ELDERS. I certainly will, Senator. I think that what we are
going to try and do is all work together to try to stop having our
programs being quite so fragmented and really try to build pro-
grams around people, rather than having people circling the wag-
ons trying to find us.

Senator Kassebaum. Will you be reporting to Dr. Lee or Sec-
retary Shalala?

Dr. Elders. Yes, ma'am, to both, to Dr. Lee and to Dr. Shalala.

Senator Kassebaum I would like to ask a question that has
come up about the Mercy Nursing Home. Your financial disclosure
form in 1989 for the State of Arkansas indicated you had a finan-
cial interest of between $1,000 and $12,500 in the Mercy Nursing
Home, which is located in North Little Rock. Could you explain
precisely what the nature of this interest was?

Dr. Elders. Senator, the owner of Mercy Nursing Home, I lived
with her mother, and I had known the family, and I worked at that
nursing home when I was a student. I had no financial interest. I
think on that form, what you have to say is if you received — it real-
ly relates to money — if you received more than $1,000, so that
block that was checked was more than $1,000. And then the other
thing, it was more than $12,000. So that really, I have no financial
interest in Mercy Nursing Home. _Mercy Nursing Home is now
closed. It was sold to others in, I think, probably the end of 1989.
So I was the medical director; I worked there for the woman, and
I lived with her mother. They had been friends all my life. So it
was more to appease them, and I was really there for approxi-
mately an hour on Saturdays.

Senator Kassebaum. And you say you lived with the mother of
the owner?

Dr. Elders. When I went to college, for a year, yes, ma'am.

Senator Kassebaum. Did you feel that having an interest in the
nursing home was in any way a conflict of interest with your role
as the director of public health?

Dr. Elders. No. The health department had no relationship to
nursing homes in Arkansas. We do not approve them, we do not
inspect them, and neither Medicare nor Medicaid is in the health
department. So as I said, it was not a financial interest. It was
payment for services, $4,800 for the year. It was approximately
$100 an hour.

The Chairman. Would the Senator yield on that point?

Senator Kassebaum. Yes.

The Chairman. Who does have responsibility? As I understand,
it is the Department of Human Services and the Attorney General?

Dr. Elders. Yes, sir.

The Chairman. Could you tell us who has the responsibility?

Dr. Elders. The overseer of the nursing homes is the Depart-
ment of Health and Human Services. They ao all of the inspections,
and of course, the Attorney General, any time there is something
found wrong or illegal or anything, the Attorney General is in-
volved. But the responsibility is really with the Department of
Human Services, not with the Department of Health.

Senator Kassebaum. Dr. Elders, I would like to skip back to the
health aspect. I know it may seem as if it is nitpicking sometimes
to go at these questions regarding financial interests and so forth,
but on the other hand, this happens to all nominees, and I think
it is absolutely essential that the record be perfectly clear.

On the school-based health clinics, you nave spoken about the
importance of those and that they are determined, based on local
school districts and local school boards. Now, is the decision wheth-
er to have them or not made by the local school district?

Dr. Elders. That's correct.

Senator Kassebaum. And then the State of Arkansas provides
the funding for those, of course, if the school board decides?

Dr. Elders. That's correct— the State of Arkansas, primarily
through the Department of Health. We used some maternal and
child health funds, other Federal funds, State funds, with the feel-
ing that they were really satellites of health departments, so we
could provide similar services in the school-based clinics that were
provided in health departments, but the rules were different.

Senator Kassebaum. Would you advocate a Federal role in
school-based clinics?

Dr. Elders. Senator, I feel so strongly about the involvement of
the community, and I feel that the community needs to make a
commitment for the bright young people. And because of that, I feel
that if funds were available, and schools applied — let me tell you
how we got started.

What we did was we said we could afford to fund 10 school-based
clinics. Out of those 10 school-based clinics, we said the first 10
schools that applied and completed all of the applications to get
one, based on need, would be funded. And we considered the num-
ber of children who were on free lunch, the number of dropouts —
the kinds of things that schools had. We didn't want them running
around trying to find a lot of different kinds of things, like the
number of children that they may have involved with drugs. Obvi-

ously, we wanted it to be in the areas of greatest need. Then, that
school board had to have a meeting and pass a resolution — and this
was before thev could even apply — pass a resolution that they
wanted a school-based clinic. It had to be an open meeting, and it
had to be advertised in advance.

Following that, the school board then could decide — let's say the
resolution was passed— then the school board would decide what
they wanted in their clinic. And as you can see, if we have 24 clin-
ics, and only four of them have reproductive nealth, you can see
that that was a frequent thing that they did not want to do — but
that was fine; that was what they decided.

But then let's say for the schools that have reproductive health,
you as a parent could say, "I don't want my child to even use the
clinic" — and that is fine; they could not get any services at the clin-
ic. Or, you could say, T don't want my child to have reproductive
health, but I would like him to have everything else." Then, they
could have everything else, but they could not have reproductive
nealth in the school-based clinic.

That was the way we did it, and we now have many schools on
the waiting list who have gone through all the procedures, and
what they really need is funding. And I think if Federal funds were
available involving local control. Senator, and they knew that they
had an opportunity to get the funds, that you would have many
schools — I would say that in Arkansas, you would probably get 90
percent of the schools.

Senator Kassebaum. If there were the public health funds in
Arkansas

Dr. Elders. If there were funds available to take care of them.

Senator Kassebaum. I was going to ask you if you had a waiting
list, and if support was growing for it.

Dr. Elders. We do have a waiting list. Support is growing for
it. We have more schools— but now the schools know we have 24
school districts on the waiting list, and that we fund them as we
can. A school district may have 10 or 15 schools, but we are talking
about 24 different school districts that are on the waiting list.

Senator Kassebaum. Mr. Chairman, Fll vield the time and will
be here for other rounds. Let me just say that Senator Gregg sent
a letter, and he said that he would probably not be able to attend
this afternoon, but he wishes to reserve the right to submit written
questions to Dr. Elders for the record, and in my absence, he would
like for me to make this reqeust.

The Chairman. That is certainly agreeable.

Senator Pell.

Senator Pell. Thank you, Mr. Chairman, for holding this hear-
ing. While I am confident that Dr. Elders will be an effective advo-
cate of many of our Nation's most, important health needs, with
which I am in basic support with you, I do have one concern that
I have expressed to you and to Secretary Shalala. That is, the Sur-
geon General's primary responsibility to my mind is as manager
and leader of the Commissioned Corps of the Public Health Service.

When we first talked about this topic, I think we had a certain
difference of view on this, but in view of your statement this morn-
ing, I was delighted to hear that you share my enthusiasm for the
Public Health Service.

Dr. Elders. I certainly do, Senator.

Senator Pell. I was much impressed with the force and the
depth of your statement this morning in that regard.

I would like to ask you if you could give me your idea of the role
of the Commissioned Corps and how you would handle it and how
you intend to lead it. I am particularly concerned because the Pub-
lic Health Service used to man the vessels, the cutters we were on
in World War II, and I have since watched the work of the Public
Health Service.

Dr. Elders. Senator, as leader of the Public Health Service
Corps and all the many bright young physicians and people who
are part of the Corps, the 11 different groups that are part of the
Corps, I would hope to be able to encourage and recruit more peo-
ple to come into the Corps as a part of the overall management.
We would work with all of the different agencies that we are re-
quired to work with — with the Department of Transportation, espe-
cially in regard to the Coast Guard and providing health services
for those individuals. We would be working, obviously, with the
States in the many things they are doing especially now in the area
of flood control. I think that we would need to be able to respond
very quickly and immediately. We would like to be able to continue
to work with the Department of Defense to coordinate health serv-
ices and health activities for all of the different branches. And obvi-
ously, we have a huge number, but as you know, many of them are
at the NIH, and they are at the FDA, CDC; they are in many dif-
ferent agencies, and we would like to continue to be able to have
the Commissioned Corps as one of the real leaders in the Public
Health Service.

I have met many of these wonderful people who are part of the
Corps, and I have been very impressed with their dedication. Noth-
ing is better than for a nation to have a ready, available service
of trained people that you can call on when you need them. I think
the recent flood is one more example of the kinds of things that
they need to do.

Senator Pell. But do we concur in the fact that your prime re-
sponsibility is as the leader of the Public Health Service, and the
other duties are ancillary to it?

Dr. Elders. My primary responsibility, Senator, will be as an ad-
vocate for health services and certainly as a leader. I think Dr. Lee
at the present time — and I would report to Dr. Lee, but I would
certainly be his advocate — is kind of considered the prime leader of
the Public Health Service, and I would respond and report to Dr.
Lee. But I feel very strongly about the Public Health Service and
being one of the leaders in that area.

Senator PELL. Just to keep the record straight, I think the line
of command goes from the Public Health Service through you to
Dr. Lee, and you are in that line of command.

Dr. Elders. And I would like to continue to develop and move
the Public Health Service forward.

Senator Pell. And what you would be specifically the leader of
is the Commissioned Corps.

Dr. Elders. Yes, sir.

Senator Pell. Is it your intent to wear the uniform, as Dr. Koop
and Dr. Novello did?

Dr. Elders. Senator, I definitely plan to wear the uniform. As
she was getting ready to leave office, Dr. Novello told me that you
never know when somebody is going to drop in and want a picture
with the Surgeon General, so you have to always be prepared. And
with that, yes, sir, I plan to wear the uniform.

Senator Dodd. You could get one of those cardboard cutouts.
[Laughter.]

Senator Pell. Another question — despite the years of nationwide
attention that the dangers of drunk driving have received, many of
our young people continue to drink and drive and die. Will you con-
tinue the work of your two predecessors in this regard?

Dr. Elders. Yes, sir. I could do nothing less. I think violence and
accidents are getting to be very high killers of our bright young
people, and we must work with everyone to try to reduce drinking
in our young people and reduce drunk driving; yes, sir.

Senator Pell. A similar question is in connection with discourag-
ing tobacco use amongst our children, which is again where Drs.
Koop and Novello took their lead in the past.

Dr. Elders. Yes, sir. In fact, the tobacco industry has already
been very concerned about some things that I have said in regard
to the tobacco industry, and Senator, we have to be concerned
when we realize the number of people that are dying as a result
of lung cancer and the high cost — $64 billion— on our health care
system. So yes, I will be out there fighting against not only ciga-
rette smoking, but against smokeless tobacco or any other use of
tobacco especially for our young people.

Senator Pell. I want to thank you for your answers, and good
luck to you in your role as commanding officer of the Commissioned
Corps. I am sure you will do a fine job. Thank you very much.

Thank you, Mr. Chairman.

Dr. ELDERS. Thank you very much, Senator.

The Chairman. Thank you, Senator Pell.

Senator Coats.

Senator Coats. Thank you, Mr. Chairman.

Dr. Elders, I apologize for not being here — I was here for your
statement, but I apologize for not being here for the opening ques-
tions. Another committee on which I serve was marking up its bill,
the Armed Services Committee, and we got right to the end, and
we always save the most contentious, controversial issues for the
end, so I was torn between the two. So if I repeat anything, I apolo-
gize; I don't intend to.

Dr. Elders. I understand.

Senator Coats. I would like to pursue a number of questions.
First of all, I want to ask you a couple of questions about the finan-
cial records. You understand and I think agreed that it was within
the committee's prerogative and appropriate for the committee to
delay your hearing a week. We had not received those financial
records, and the reason why we wanted to receive those financial
records was for the purpose of dealing with the questions and alle-
gations that had been raised relative to your financial affairs. So
looking at those records, I think, was appropriate.

Now, we have received some, but not all. Most of what we re-
ceived was either very late last night or early this morning, which
really didn't give us adequate time to go over them. However,

records which go to this whole question about the Social Security
payments would necessarily come from your tax returns, and my
understanding is you have declined to make those tax returns
available. Is mat a correct understanding?

Dr. ELDERS. That is correct, Senator.

Senator Coats. Do you feel that that is appropriate in that a
question has been raised relative to failure to pay Social Security
taxes that were due, and we do not have the records to

Dr. Elders. The Social Security, Senator, was for my mother-in-
law; it was filed on my mother-in-law's returns. I do not feel that
my mother-in-law is really a part of these hearings. It is separate.
My husband has power of attorney. The Social Security has been
paid.

Senator Coats. I understand that. I guess my

The Chairman. Would the Senator yield on this issue? Under the
practice of this committee, if the Senator is interested in having a
briefing from either the IRS or Social Security on the details of
these matters, any member of the committee, and any member of
the Senate is permitted to have that briefing. But we have recog-
nized a modicum of privacy, particularly when the documents in-
volve another person and are not directly related to the nominee.

Any question that you have with regard, to her taxes or Social Se-
curity, you will be briefed in as much detail as you would like. The
FBI has made available to us their conclusions on this matter.

So we should have some perspective on this issue. The only time
we have had complete tax information was from Secretary Lamar
Alexander, who voluntarily supplied it.

Senator Coats. I understand that, Mr. Chairman.

My question was do you plan to submit them or not, and you an-
swered no, and that is the end of the question.

Dr. Elders. Right.

Senator Coats. I do, then, have some questions relative to that
Social Security issue that I think we ought to clarify so we can put
this issue to rest. It obviously has been an issue in other nomina-
tions on payment of this tax, and in that it has been such a promi-
nent issue, I think it would be important to get some answers for
the record if I could.

Could you describe for us the nursing arrangement that you and/
or your husband established for your mother-in-law?

Dr. ELDERS. All right. The nursing arrangement, Senator, was
initially established by my father-in-law to take care of his wife,
and we continued those arrangements. My husband had power of
attorney, and he paid this nurse most of the time, but I did pay
her sometimes.

Senator Coats. Was that Audrey Ruffin?

Dr. Elders. Yes.

Senator Coats. And who hired Audrey Ruffin?

Dr. Elders. My father-in-law, Oliver Elders, Senior.

Senator Coats. And where did she work?

Dr. Elders. She worked taking care of my mother-in-law at my
house.

Senator Coats. And she was a private nurse?

Dr. Elders. She was a home health aide, and that was her pri-
mary responsibility. She worked about 6 to 7 hours per day. I

would get up each morning and, before I would go to work, get my
mother-in-law up, bathe her, feed her, and take care of her nec-
essary things, and put her in the chair, because we were trying to
use just one person. And I would care for my mother-in-law on the
weekend. But Ms. Ruffin was there every day, and she took excel-
lent care of my mother-in-law, and that was her only job.

Senator Coats. Did you and/or your husband basically dictate
her responsibilities and the hours that she was to

Dr. Elders. That had really, as I said, been arranged by my fa-
ther-in-law, and we kept that arrangement. I was gone when Ms.
Ruffin came; I was already at work. She left before I got home.

Senator Coats. If you were going to travel at a different time,
or leave earlier or leave later, did you have

Dr. ELDERS. Senator, I caught planes at 6:45 in the morning. I
would get my mother-in-law up, bathe her, feed her, and put her
in the chair

Senator Coats. I understand that.

Dr. Elders. — because the most important thing for me was that
she was very comfortable.

Senator Coats. I understand that, Dr. Elders.

Dr. Elders. This was a woman who, when my children were
very small, and I was having to work very long, hard hours, espe-
cially during the summer, would come and take my children and
keep them for a month, and take them to Disneyworld and places.
And every summer, she would keep my children for a month for
me, for a rest.

Senator Coats. Dr. Elders, I

Dr. Elders. So now, I don't have any problems taking care of
her.

Senator Coats. I understand that.

Dr. Elders. And yes, when I left at 6 in the morning

Senator Coats. You misunderstand my question, Dr. Elders.

Dr. ELDERS. Oh, I'm sorry.

Senator Coats. I perhaps did not State it clearly.

Dr. Elders. Oh, I'm sorry. I thought you said when I was
going

Senator Coats. I think it is very admirable what you did, and
I can appreciate the difficulty of doing that, and I can find

Dr. Elders. I never considered it a difficulty, Senator. I felt that
I was doing

Senator Coats. I am trying to be sympathetic, empathetic.

Dr. Elders. Well, I don't want you to be sympathetic. [Laugh-
ter.] I am telling you that

The Chairman. She doesn't need it; that's what she's telling you.

Dr. Elders. — this is something X have done with pride because
she did it for me.

Senator Coats. My question was could you have called up Au-
drey Ruffin and said, "Audrey, I have to leave at 6:45. Could you
come earlier today"— or tomorrow — were you able to do that, or did
you do that?

Dr. Elders. Now that I am here, Senator, and my husband is
here, too, Audrey Ruffin is taking care of my mother-in-law.

Senator Coats. I understand that, but my question is who made
the arrangements for Audrey Ruffin- in terms of what time she
would show up for work and how long she would have to stay?

Dr. Elders. That had really been prearranged by my father-in-
law. She always looked good, and she was always well taken care
of, so I didn't see her. And I know it sounds

Senator Coats. OK. Let me go on to another question. I am not
able to State that with sufficient clarity. Did Audrey Ruffin ever
live with you?

Dr. Elders. No, sir.

Senator Coats. Was she paid by checks drawn from your joint
checking account with your husband?

Dr. Elders. Yes, sir.

Senator Coats. Have you ever signed a check or made payments
to Audrey Ruffin for services received?

Dr. Elders. Yes, sir.

Senator Coats. Have you ever signed a check or made payments
for services rendered to Leona — excuse me — maybe it is divine
intervention; maybe I am not supposed to ask these questions.
Now, is Leona Elders your mother-in-law?

Dr. Elders. Yes, sir, she is my mother-in-law.

Senator Coats. She is your mother-in-law. All right. Now, is it
true that Social Security and unemployment taxes were not with-
held from Ms. Ruffin's wages while she was in your employ?

Dr. Elders. That's correct.

Senator Coats. And were Federal and State taxes withheld from
her salary?

Dr. Elders. No, sir.

Senator Coats. Did either you or your husband consult with a
lawyer or tax expert regarding your mother-in-law taking a deduc-
tion for services which she did not pay? Did you ever contact a law-
yer or a financial consultant or a banker to try to understand what
the arrangements were?

Dr. Elders. No, sir. Senator, I

Senator Coats. I am not commenting on whether this

Dr. Elders. Well, I guess I'm saying

The Chairman. Could you restate it, Dan? I am trying to follow
it myself.

Senator Coats. Did either you or your husband consult with a
lawyer or a tax expert regarding your mother-in-law taking a de-
duction for services for which she did not pay? In other words, on
your mother-in-law's return

The Chairman. Did you consult with a lawyer about your moth-
er-in-law's taxes to get advice as to -whether she could take a medi-
cal deduction?

Senator Coats. Or any other deduction.

Dr. Elders. No, sir. Well, our tax accountant handled that, and
this was

Senator Coats. You didn't raise the question with them.

Dr. Elders. No, sir.

Senator Coats. When did you realize that what was done here
was a violation of the law in terms of not paying the taxes?

Dr. Elders. Well, Senator, I guess even today, I don't feel that
it was a violation of the law in regard to me. but I think it was
an error that was made in that my husband didn't pay.

Senator Coats. Well, whether we agree with the law or not, the
law states that it is a violation. Did you at some point realize that
it was a violation of the law as written?

Dr. Elders. Well, I guess the past few weeks, I guess I did.
When we found out, we paid it, but it was not a violation, I don't
think, for me.

Senator Coats. But you did at some point realize that the law
had been violated relative to the taxes and Social Security.

Dr. Elders. Yes.

Senator Coats. As the director of a State health department,
were you familiar with the practices and procedures for hiring pri-
vate nurses?

Dr. Elders. Well, Senator, I did not get into all the details of
personnel policy at the Department of Health.

Senator Coats. So you were not aware then that there were cer-
tain legal responsibilities relative to tax payments and so forth to
private nurses.

Dr. Elders. Senator, it was my understanding — and this had
been some of our understanding in regard to this — that private-
duty nurses really are independent consultants or independent con-
tractors, and they handle their own — you pay them a fixed amount,
and

Senator Coats. Your husband, when asked why he failed to
withhold the taxes, said it was because he couldn't afford to pay
them; yet there has been a lot written about your salary and your
husband's combined salary with yours. Was that an accurate state-
ment? Was that a fact, that you could not afford to pay the taxes
on the nurse hired to take care of your mother-in-law?

Dr. ELDERS. Senator, I would not like to answer in regard to
what my husband said, because I didn't hear him make that state-
ment.

Senator Coats. Well, could I have your opinion as to whether or
not you thought you and your husband had sufficient income to pay
the taxes?

Dr. Elders. Fm sure, Senator, we would have — you know, you
always have sufficient income to do what you have to do.

Senator Coats. Well, I guess my question goes to whether or not
you thought you were supposed to pay the taxes, or you thought
that you just did not have enough money to pay the taxes.

Dr. Elders. Senator, again, these were my mother-in-law's
taxes

Senator Coats. Dr. Elders, listen, I can-

The CHAIRMAN. Let her answer. She is trying to answer.

Senator Coats. Well, it wasn't answering the question I asked,
but I'll be patient.

The Chairman. She is entitled to give any answer if she can an-
swer, the question as it has been phrased.

Senator Coats. I am sorry, Dr. Elders. I didn't mean to interrupt
you.

Dr. Elders. Well, I guess what I was really saying was these are
really my mother-in-law's taxes. There is my husband, and he has

two sisters. Our agreement was that he would take care of what
needed to be done with his parents. I was not involved in their fi-
nancial affairs. His mother-in-law had funds that I know that we
paid Ms. Ruffin.

So I was just not involved in their day-to-day affairs. Maybe I
should have, but I wasn't. To me, the most important thing that
I had to do was to provide the best possible health care that I could
for my mother-in-law.

Senator Coats. Mr. Chairman, I should inquire how much time
I have left on this round, because I have another series of questions
that I don't want to start if I am going to run out of time halfway
through.

The Chairman. One minute.

Senator Coats. Well, I can't make it through the series of ques-
tions, then. I'll wait for the second round. I'd be happy to do that.

The Chairman. If Senator Metzenbaum would just yield for a
few moments so that I can address the Social Security matter. As
I understand it, in 1985, Leona Elders executed power of attorney
in favor of her son, Oliver Elders. Leona is your mother-in-law. Is
that right?

Dr. Elders. Yes, sir, that's correct.

The Chairman. Now, your mother-in-law and your father-in-law
came to live in your home.

Dr. Elders. Yes, sir.

The Chairman. The parents of your husband.

Dr. Elders. Yes, sir.

The Chairman. And they were the people who initially estab-
lished a relationship with Audrey Ruffin; is that correct?

Dr. Elders. Yes, sir.

The CHAmMAN. Due to their failing health, Mr. Elders and Leona
Elders moved into your home with you and your husband. Now, in
the summer of 1988, O.B. Elders, your father-in-law, hired Ms.
Ruffin to care for his wife who was suffering from Alzheimer's dis-
ease.

Dr. Elders. Yes, sir.

The Chairman. And O.B. Elders arranged to pay Ms. Ruffin
without Social Security taxes, and shortly thereafter, O.B. Elders
died; is that right?

Dr. Elders. That is correct, sir.

The Chadxman. Then, from 1988 to 1993, your husband contin-
ued to employ Audrey Ruffin under the same conditions as his fa-
ther had employed her, and Audrey Ruffin was paid from Leona El-
ders' funds.

Dr. Elders. That's correct, sir.

The Chairman. So the funds that you are talking about were ac-
tually the funds of your mother-in-taw

Dr. Elders. Thars correct.

The Chairman. — that your husband had access to, and he used
those funds to pay for this attendant.

Dr. Elders. Yes, sir.

The Chairman. And when you signed checks, you signed checks
for that amount of money — even though it is a joint account — that
amount of money that belonged to your mother-in-law; is that
right?

Dr. Elders. Yes, sir.

The Chairman. And recently, your husband Oliver acknowledged
that he was obligated to withhold the Social Security.

Dr. Elders. Yes, sir.

The Chairman. These were your husband's parents.

Dr. Elders. Yes, sir.

The Chairman. You love them as family, but they are your hus-
band's parents. Now, I love my wife's parents, too, I just want to
make that clear; I don't know whether they are out there watch-
ing—[Laughter.]

Oliver Elders now acknowledges that he was obligated to with-
hold the Social Security tax, and he has paid approximately
$15,000 in back taxes to the IRS.

Dr. Elders. Yes, sir.

The Chairman. OK. You never took any kind of deduction in
your taxes to the best of your knowledge.

Dr. Elders. No, sir.

The Chairman. Not even to the best of your knowledge — you
didn't take any.

Dr. Elders. No, sir. Her taxes were filed as Leona Elders every
year.

The Chairman. But you never took any.

Dr. Elders. No, sir.

Senator Coats. Well, did you and your husband file a joint re-
turn?

Dr. Elders. Yes, sir.

Senator Coats. Did that tax return reflect any deductions that
were taken?

Dr. Elders. Not for Leona Elders.

Senator Coats. There were no deductions taken for Leona Elders
on the joint return filed by you and your husband.

Dr. Elders. For us, no, sir.

The Chairman. Well, I thank you. We have other questions, but
Fll come back to them.

I yield the remaining time, Senator Metzenbaum.

Senator Metzenbaum Dr. Elders, Fm not sure what we are here
about, whether we are here about whether you ought to be Surgeon
General, or whether your husband should have paid Social Security
taxes, but I understand the questions, and I respect my colleagues'
inquiry along that line.

I must say for myself that I think there has been more to-do
about this whole question of the Social Security taxes than maybe
has been warranted, and I really want to be sure you are a law-
abiding citizen, which I am confident everybody agrees you are.
Senator Hatfield speaks up for you, Senator Boren speaks up for
you, Representative Lambert speaks up for you and knows you
well.

And I think that we can sometimes get diverted. I am a little bit
concerned that nobody cares too much about taxes and the banking
situation, which I have looked into, and I am satisfied; you have
a very clean record, and there is no problem about it. You got a
letter from some governmental authorities, but you were just a
member of the board of directors. There is no question that you
borrowed money from the bank, that you paid back the money to

the bank, that you didn't get any special interest rate. I have
looked into all of those questions, because if there were something
basically wrong with your integrity, I would have difficulty voting
for you. I am satisfied that you nave the utmost in integrity. Either
you have integrity, or you do not, and I have satisfied that you
nave integrity.

Dr. Elders. Thank you, Senator.

Senator Metzenbaum So then the next question is, are you ca-
pable of being Surgeon General of the United States. Now, to hear
some of the people who have spoken out for you and to read about
your record, I have never had the privilege of meeting you before,
but I have the feeling that if I didn't vote for you, I might feel the
same way I felt about Dr. C. Everett Koop. I did not vote for him,
and I made a mistake. And I don't intend to make that mistake
now, and I hope this committee and this Senate does not make that
mistake.

You are an unbelievably capable, aggressive, aggressive woman,
and I think that's what we need in fighting some of the problems
in this country. The whole problem of children and HIV/AIDS is
not going to take a passive attitude; it is not going to be the kind
of subject that it going to solve itself. The problem of teenage preg-
nancy is incredible. And whether you maae great progress or vou
did not make great progress, everybody has to stand up and salute
you for having maae the effort. There are some things that you
can't do that much.

Then, I read some articles in the paper about the availability of
condoms and the fact that some of the condoms were defective, and
whether you should have gone public or should not have. I don't
know. Maybe you should have. I am not sure. But I am interested
in the health of the people of this country, and for myself, I am sat-
isfied that you are a breath of fresh air. You are going to go in and
do that job; you are going to get confirmed, and you are going to
get confirmea by an overwhelming vote, and I think you are going
to do a fantastic job for the health care needs of this country.

Some right wing groups are going to be unhappy because you are
aggressive in speaking out about some of these issues having to do
with sex, having to do with venereal disease, and having to do with
certain other issues of that kind. But that is their problem. I think
that you are going to do a fantastic job, and I am just so pleased
that 1 have had the privilege of meeting you here today. I never
had that privilege before, and I wish you well.

Dr. Elders. Thank you, Senator. Til do the very best that
Joycelyn Elders knows how.

Senator Metzenbaum. Thank you. Good luck.

The Chairman. Thank you, Senator Metzenbaum.

Senator Dodd.

Senator Dodd. Thank you, Mr. Chairman. I would ask unani-
mous consent that my formal remarks be included in the record.

The Chairman. Without objection, so ordered.

(The prepared statement of Senator Dodd follows:]

Prepared Statement of Senator Dodd

Mr. Chairman, I speak today in strong support of President Clin-
ton's nominee for U.S. Surgeon General, Dr. Joycelyn Elders. De-

spite her numerous qualifications and the many endorsements she
has received, I fear her confirmation will be contentious. I hope
that we can focus on her accomplishments and the promise that
she offers the country, and not tear apart a nominee with a strong
commitment to public service.

Dr. Elders has proven throughout her career as a pediatrician
and public servant that she will be a strong champion for the pub-
lic health of the Nation — particularly for the well being of children.
Dr. Elders and I share this focus. It is because of the promise that
she offers to the Nation's children that I went to the floor last week
to speak on her behalf.

It is clear to anyone that looks at the many educational and pro-
fessional accomplishments on her resume that she is highly quali-
fied for the job. But her distinguished resume is only part of the
story. Dr. Elders is well-known not just for her resume But for her
actions — most important, her willingness to take on difficult prob^
lems.

I had the pleasure of meeting Dr. Elders recently. We discussed
the problems and obstacles faced by our Nation's youth. We talked
about a problem of particular concern to me — youth violence. Dr.
Elders understands the relationship between the high rate of vio-
lence and other social problems.

She knows that health problems and other social ills are linked.
She knows that to improve health we must also address the related
problems of drugs, alcoholism, homicide, suicide, accidents, AIDS,
and teen pregnancy.

For almost 6 years, she served as director of health for the State
of Arkansas ana became known for her ability to draw attention to
the health needs in her State and the special needs of youth. Ar-
kansas organizations that take a special interest in these mat-
ters— such as the PTA and the medical society — are quick to point
out her leadership. She oversaw major public health improvements
in Arkansas, including improved childhood immunization rates,
childhood screening, and prenatal care programs.

Mr. Chairman, our country faces many public health problems —
an appallingly high infant mortality rate, an AIDS epidemic, low
rates of immunization, and teen pregnancy — to mention a few. We
need a surgeon general who is willing to tackle difficult issues and
bring them the attention they deserve, as was the case with Dr. C.
Everett Koop.

In my own State of Connecticut, more girls in Hartford have ba-
bies than graduate from high school in a year. I read in the Hart-
ford Courant this week that in the city of New Haven, CT, % of
10th graders, Vz of 8th graders, and more than Ya of 6th graders
reported in a recent survey that they have had sex.

We cannot ignore these realities and we certainly cannot accept
and address them only after the fact. Dr. Elders has expressed her
commitment to change these sorts of statistics so that our young
people can finish school, take control of their lives, and hopefully
break the cycle of poverty.

Dr. Elders' opponents claim she is a radical with dangerous
ideas. They say that she will tarnish the innocence of children.
They say all this, even though Jovcelyn Elders' actions have ad-
vanced the health and well being of children.

Dr. Elders ideas and goals are ones that I believe most of us
would agree with. She wants to keep, children healthy by educating
them to avoid harmful behavior. She also wants to provide them
with access to primary and preventive care. Dr. Elders saw that
children weren't using the Arkansas' public health clinics, so she
established clinics in the schools. The clinics reach children who
otherwise would not have access to health care. This is not radical
or dangerous. It is common sense.

Dr. Elders has said that she supports age appropriate com-
prehensive health education. Unfortunately, this sensitivity to age
does not apply to the soap operas and other television shows that
children can view by simply turning on the television at 3 in the
afternoon. Dr. Elders recognizes that children get messages about
sexuality from many sources whether we like it or not. She pushes
to educate at younger ages to make youth more responsible and
healthier, not to tarnish their innocence.

Opponents of Dr. Elders' nomination will try to make her out to
be an extremist. I believe, and hope that my colleagues agree, that
Dr. Elders' willingness to speak out on difficult issues and not bow
to political pressure does not make her extreme. It distinguishes
her as a leader.

The most respected institutions have recognized and honored her
leadership. As of July 9, close to 100 private, private nonprofit, and
public organizations had endorsed her nomination, including the
American Medical Association. Both the current and a former com-
missioner of health of my own State of Connecticut have written
to me in support of Dr. Elders. They know and have worked with
her and they know the health problems that face Connecticut. They
believe that the State and the country needs Joycelyn Elders.

And what do the people of Arkansas have to say? She has re-
ceived the strongest endorsements from groups in Arkansas. The
Arkansas Chapter of the Society for Public Health Education, the
Arkansas Hospital Association, the Arkansas Medical Society, the
Arkansas PTA, and the Arkansas Public Health Association all
have endorsed Dr. Elders.

I look forward to hearing from Dr. Elders this morning and hope
that this committee will focus on the promise that she oners to the
Nation, particularly for our youth. I strongly support her nomina-
tion.

Senator Dodd. Dr. Elders, welcome once again to the committee.

I would just point out, Mr. Chairman, and to my colleagues here,
that I had never met you until you came by the office. I am pleased
that you took the time to visit.

I always think it's a pretty good test to go back to one's neigh-
bors, coworkers, friends, or other people who may have known you.
Not that it is necessarily an absolute test, but it is a pretty good
one, generally speaking. I am always a little cautious about endors-
ing people who haven t been endorsed by people that they have
worked with in the past and who know them. And for those who
may not know you well and who are only becoming familiar with
your views in tnis setting, I think it is very important to note for
the record that over 100 organizations have endorsed your can-
didacy, including such radical groups as the Parent-Teacher Asso-
ciation of Arkansas and the Arkansas Medical Society. My commis-

sioner of health and a former commissioner in the State of Con-
necticut who know you, strongly endorse your candidacy. Other
health organizations in your State have voiced their support — the
list goes on and on.

I think that this is very worthwhile information when trying to
make judgments based on your almost 6 years of work at the De-
partment of Health and on your previous academic and profes-
sional involvement.

I suspect that every one of these organizations that have en-
dorsed you did not agree with everything you did or every word you
have spoken; I have read a few of the things you have said, and
I have a little difficulty with the way you nave articulated some
views, but that is not the issue here. For those who may be trying
to make a judgement call as to whether or not you are competent
or qualified, I think what is important is whether or not you have
demonstrated the kind of leadership, involvement, and forthright-
ness that is critical in this job.

I took the floor a week or so ago on your behalf after I had met
you and talked to you. I decided early on that I wanted to express
my strong views. And I said at that time that we don't like to
admit mistakes up here; Senators are really dreadful at admitting
that we have cast votes that we would like to have back. There
have been a few in my 12 years that I would like to have back, and
one of them is my vote on Dr. C. Everett Koop. I voted against him,
and I regret it, because he turned out to be one fine Surgeon Gen-
eral.

And one of the reasons I got to like him so much — not that I
agreed with him on everything — is that I liked his forthrightness;
I liked the fact that he didn't mince words, and he laid out issues
before this committee and the Congress and the American public
that we had to come to terms with. He turned out to be a terrific
leader on these issues. Not that you are going to necessarily follow
a similar path on views, but you share the same forthrightness
that I think is critical.

Of course, we are told that you are a radical and dangerous indi-
vidual. I look and I see that you care about such issues as teenage
pregnancy and substance abuse. In a sense, those are radical ideas,
in the true sense of the word, "radical." We have been ducking
these issues for a long time, and maybe we need to come to terms
with them and should have a long time ago. The fact that you have
brought them up in the State of Arkansas, I think is extremely
worthwhile.

So I welcome your nomination. I think the President made a ter-
rific choice. I am glad you accepted the challenge. I am sorry you
have had to go through some of this, but that is what people have
to do. It is worth it, in my view, in. the end, because I think the
American people are going to come to know you and respect you.
I think your statement this morning was tremendous, and I am
confident you'll do an excellent job.

I made the offer earlier to the chairman to yield my time be-
cause, and I do want to get back into the other lines of questioning.
So Fll yield my time to you to complete that cycle, if that is what
you'd care to do, Mr. Chairman.

The Chairman. I would like to do that if it is agreeable.

Senator Dodd. Ill do that and reserve specific questions.

The Chairman. There are still a couple of areas; let me go
through one additional area and then yield to Senator Simon, if
that is all right.

Finally, on the Social Security issue, your husband had a power
of attorney for his mother's funds; is that correct?

Dr. Elders. That? s correct, sir.

The Chairman. He was designated with the power of attorney,
officially.

Dr. Elders. Yes, sir.

The Chairman. Now, on the issue of the alleged double-dip sal-
ary, my understanding is that it is common for Federal nominees
like yourself to work as consultants before they are actually con-
firmed. In spite of this, you have been accused of some double-dip-
ping.

Hasn't the ethics officer for the Department of Health and
Human Services — who, incidentally, served as an ethics official in
the Reagan and Bush administrations — already made an authori-
tative judgment on this question?

Dr. Elders. Yes, sir.

The Chairman. Could you share that judgment with us, Dr. El-
ders? Ill put in the record at this time the letter that was sent to
me as part of the record, but Fll give you an opportunity to respond
to that question.

[The letter referred to may be found in the appendix.]

Dr. Elders. Senator, in regard to what he said, it was my im-
pression that he said that what I was doing, there was nothing, no
rule or anything against it. But if I can just tell you what hap-
pened, you had vacation days, and we have a rule in Arkansas —
and I had asked for leave of absence and had been granted leave
of absence without pay — but you can't take leave of absence with-
out pay until you have used up all of your vacation days.

So I was using earned vacation days. It was in no way — I did not
see that as double-dipping. If I had left immediately, if I had come
here in January or something of that sort, I would have received
a lump sum payment for 60 days. And we reviewed all of the
records from Arkansas, and there is no rule against what I have
done.

The Chadiman. Ill just put in the record the letter from Jack
Kress who, as I said, also performed as special counsel under the
previous administrations. Ill put the full letter in the record, and
I'll read certain parts.

"I therefore have a close working familiarity with the practices
of two Cabinet departments with respect to incoming Presidential
appointees in the Reagan, Bush and Clinton administrations.''

"It is to my knowledge common practice throughout the executive
branch for incoming Presidential appointees to retain their former
positions until such time as they are confirmed by the Senate."

"Prior to confirmation, such nominees may, however, legally join
the department in an intermittent consulting capacity. Moreover,
from the perspective of Federal law, there is no impediment to the
receipt of payments by an intermittent consultant from that per-
son's current non-Federal employer, for as long as that person re-
mains a special Government employee."

And then it continues, "M. Joycelyn Elders, M.D., began service
as a consultant to HHS on April 18, 1993, on approximately a 2-
day-a-week basis until July 6, when she began working for HHS
on approximately a 5-day-a-week basis. As of this date, she has
been employed for approximately 30 workdays."

There is a legal limit of 130 days.

Dr. Elders. Yes, sir.

The Chairman. And this indicates that it was 30 days — 2 days
in the beginning and then, as I understand, as these hearings were
announced, it became more intense.

Dr. Elders. Yes, sir.

The Chakman. The historic background is that when people are
designated in the confirmation process, people sometimes leave
their jobs, and they are in somewhat of a hiatus during the con-
firmation period and prior to the time the Senate is going to act.
And a lot of people can't afford to just be out there. And it has been
a time-honored precedent to permit a consultant fee during that pe-
riod of time. That has been done with the other departments and
done through other administrations, even in spite of the fact that
you have resigned, and even though you could have been legally
absent because of vacation days in that particular position.

Dr. Elders. Yes, sir.

The Chairman. Well, I just want to tell you we are going through
probably one of the slowest processes — I am not trying to lay tne
blame on that. I think there is generally enough blame to go
around. But it is the slowest process that we have seen. I am very
hopeful that we will be able to move you through the process, but
there are those who would like to delay it even further. I hope that
won't happen, but I would think it would be extremely difficult for
anyone to De able to meet their own family responsibilities through
an extended process without pay.

Senator Kassebaum. Mr. Chairman, if you would just yield a mo-
ment, I would just like to note for the record that Dr. Elders' pa-
pers did not come to the Senate until July 1st, and then we were
in a week's recess.

The Chairman. That's fine. She was on a 2-day-a-week until July
6, so it was after the papers had actually been sent up that she
became closer to full time. That's fine. Thank you.

Senator Simon.

Senator Simon. Thank you, Mr. Chairman.

We thank you. Dr. Elders.

Let me enter into the record the letter from the American Medi-
cal Association, which is anything but a perfunctory letter of en-
dorsement. It talks about your exceptional leadership, and it is a
very strong letter of endorsement.

The Chairman. Without objection,.

[The letter referred to may be found in the appendix.]

Senator Simon. Incidentally, one of the other things I like, and
I hope you will forgive me — I heard Senator Metzenbaum whisper
to Senator Dodd here a few minutes ago: "I think shell really
shake things up." And I think you will. That is what we need,
someone who is willing to go out and do the courageous thing.

Another thing I like is that you have been working on the pre-
vention side. And you mentioned the school with a 57 percent teen-

age pregnancy rate. One of the criticisms Senator Metzenbaum
mentioned was that at one time, some of the clinics where condoms
were distributed, they were defective.

Dr. Elders. Yes, sir.

Senator Simon. How do you respond to that particular criticism?

Dr. Elders. Senator, what happened was that we had approxi-
mately 10 instances from four clinics in our health department that
reported that they had had some breakage. It was 10 different
condoms from four different clinics. So we pulled a batch of
condoms, and we called the FDA, and we reported it. So the FDA
came in and picked up the condoms and did preliminary testing,
or the testing that they do, and found that the condoms were defec-
tive, that 95 percent of them — I think what is allowed is four
breaks per 1,000, and what they were finding was five breaks per
100, which meant that that was a very high Breakage rate. So the
FDA pulled the condoms, notified the company, and was going to
do a seize order. The company voluntarily agreed to pick up their
own condoms, and they were sending us a different strength or a
different kind of condom. So it was looked into, and we were con-
cerned about the second batch of condoms. Again, the FDA looked
into it, and then I think we went to buying condoms from a dif-
ferent company.

So I think the talk now is, well, why didn't we, I guess, notify
the world. And our feeling was that we had reported it to the FDA,
and the FDA was doing the things that they usually do in this re-
gard, and the agreement was that there had been more breakages,
we were having real trouble with getting our people all over to use
condoms, and we felt that many of our young men felt that, well,
they'll break, so they are no good — and rather than having a great,
big fervor about it, I think the decision was made at the staff level
that what we would do is just let the FDA handle it in the way
they usually handle it, and not go out and make a public announce-
ment. And I think that is probably what — and they discussed it
with me later, and I concurred in that. I felt that as a public health
official, I was thinking of what was the greatest good, I guess. And
sometimes we really have to make tough decisions. And you might
say, well, I made the wrong decision. I don't know. But it was the
Department of Health that reported to the FDA, and it was their
response back, and I think we all agree on it. The Department of
Health in Arkansas could not keep the FDA from making a report,
but they worked with the company, and we felt that it was worked
out.

Senator Simon. I thank you.

In connection with teenage pregnancies, you also mentioned that
poor children are three times more likely to have pregnancies. My
hope is that while the area of poverty is not your primary respon-
sibility, I hope you will continue to get that message out, because
as more and more of our children are poor, we in fact are
compounding all of the problems in our society.

Dr. Elders. Senator, that is exactly correct, and if they are poor
and not doing well in school — if they are poor, they are far more
likely to be at the bottom of the class and not doing well in school;
I think we all know that — but if they are poor and not doing well
in school, they are nine times more likely to be a teen parent.

Senator Dodd. Would my colleague yield just on that one point?

Senator Simon. I will be pleased to yield.

Senator Dodd. Yesterday, we asked for a General Accounting Of-
fice study done on that, and while the population of 3- and 4-year
old children since 1980 increased by 16 percent, the number of poor
children of that age in this country in the same period increased
by 28 percent. The numbers are running in all the wrong direc-
tions.

I apologize for interrupting.

Senator SlMON. No; you simply reinforce that.

Two of your predecessors, Dr. Elders, have issued warning about
television violence.

Dr. Elders. Yes, sir.

Senator Simon. They did that after the National Institute of
Mental Health had studies on two occasions saying violence on tel-
evision is adding to violence in our society.

My hope is tnat you will continue to follow this area, where I
think we are starting to make a little bit of progress, but frankly,
we need all the help and attention we can give it.

Dr. Elders. Senator, you know I feel very strongly about this
area and about the area of violence. "One of the things that bothers
me so greatly is that it is so much higher in young black men —
the guns, the death. In fact, it is several-fold higher in young black
men. And when I think of the fact that only one out of five of our
young black men will ever grow up and earn enough money to raise
a family; two out of five will be lost to drugs and alcohol; one out
of the five will be killed through violence, black-on-black crime; and
one out of the five will be in prison — we have more young black
men in prison, Senator, than we have in college — to me, that is a
real tragedy.

Senator Simon. No question. And it is a preventable tragedy.

Dr. Elders. A preventable tragedy.

Senator Simon. That is the real key, and we have to save our

Dr. Elders. So you have my commitment that I will certainly be
working, trying to reduce violence.

Senator SIMON. In that connection, you also mentioned weapons.
And again, that is usually not considered part of the jurisdiction
of the Surgeon General. But I hope you are willing to shake things
up here also, and tell us if you agree that something ought to be
done about the proliferation of weapons in our society.

Dr. Elders. Yes, sir.

Senator Simon. Do you have an opinion on that?

Dr. Elders. I agree with what you have said. We have got to
find a way to be able to begin to deal with guns, knives. I was in
Kansas City, and they asked the students, If you were given $1
million, what you would you buy for your school if you could buy
anything you wanted?" And it was so sad to me when they said
that they would buy a metal detector so they could feel safe in
their schools.

Senator Simon. That is a real comment on where we are.

You mentioned drugs. We now spend about three-quarters of our
drug enforcement money at the Federal level on the police side. We
spend one-fourth on education and treatment. And if you were to
add incarceration, that probably goes up to 98 percent.

We have been trying to solve the drug problem by putting people
into prison. In 1980, we had 134 people per 100,000 in our prisons.
Today, we have 455 per 100,000— far more than any other country.
South Africa is second with 311.

Dr. Elders. That's correct.

Senator Simon. Canada has 109.

Dr. Elders. That's correct.

Senator Simon. Obviously, a major public health problem is the
problem of addiction, not simply to drugs, but also to alcohol. What
are your observations? Do we need to get a better balance in what
we are doing in this area of reducing drug addiction?

Dr. Elders. Senator, I certainly very strongly feel that we have
got to look at a different way. And of course, I nave always felt that
we have drug education, AIDS education, but they are all separate
programs, with different funding strains, with different people
going in to talk about it as if they were all separate and different —
drugs, AIDS, sexuality, and so on. But many times, they are part
and parcel of the same problem rather than multiple problems.

I feel that we have got to start early, Senator, educating our chil-
dren. Maybe yours are doing fine or don't need the education, but
there are many children born into single-family households who do
not have the opportunity to have the whole comprehensive health
education programs that they need in order to make a difference.

I feel that we need to look, and I think we are beginning to look,
at how can we consolidated all of these programs to really make
them a part of our school system so that we can have a comprehen-
sive program to start early and make a difference in the lives of
children, so that they can make a decision. That is not to say I am
leaving out the older ones, but I feel if we don't begin to address
some of the problems early and make it continuous, we are just
going to continue to add more and more people onto the fire.

So I very strongly support looking at the programs as a com-
prehensive one ratner than a single entity, including violence and
all the things we talk about; we have got to teach our children how
to deal with violence with means other than weapons.

Senator Simon. My time is about up, but that means also not
only the education, which you have just stressed in your answer,
but having treatment available for people.

Dr. Elders. Absolutely.

Senator Simon. In one State, people have to now wait 9 months
to get treatment for drug addiction. That is just social dynamite.

Dr. Elders. That's right. I was very pleased — you were talking
about working with groups — I was very pleased with a judge down
in Arkansas who had looked at alternate methods of handling prob-
lems, rather than, when they do something, you put them in jail.
What this judge did was he got the health department, the voca-
tional education department, and using the police system, all of
these were organized together, and for these young people, he com-
mitted them — if they didn't have an education, they had to get
their G.E.D.; if they were having drug problems, they had to come
in every day to work on that problem and to really learn
parenting— or whatever their problems were. And it did not cost us
any more money. He iust pulled us all together, all the resources
that were there, available in his county, to begin to address the

needs of the people that he had, which were costing him a fortune
in jail.

Senator Simon. Dr. Elders, I think the Nation is fortunate to
have you in that chair right now.

Dr. Elders. Thank you, Senator.

Senator Simon. Thank you.

Thank you, Mr. Chairman.

The Chairman. Senator Durenberger.

Senator Durenberger. Mr. Chairman, thank you.

Let me begin first by thanking the chair and especially the rank-
ing member for the way this morning was handled. I think it was
obviously a difficult situation for everyone here, including you as
the nominee, and I appreciate the way both of them handled it.

I would also like — you may not agree with all this — but I want
to compliment my friend from Indiana. I have gotten to know him
pretty well, and I hope you do, too, over time. You are not going
to find anyone, even on this committee, as committed as he is to
children to families and the things that you are committed to, and
I do hope that you will take the time to get to know him as well
as some of the rest of us do.

I certainly welcome you to this town. I don't know how long you
are going to enjoy it. It doesn't get much better than this right
now. [Laughter.]

Dr. Elders. Please. [Laughter.]

Senator Durenberger. But I want to remind everybody of what
you already know, that Dr. Elders spent most of her life in Arkan-
sas, but she spent a whole year in Minnesota, and they haven't for-
gotten her. Her professor at the University of Minnesota, where
she was a pediatric intern, is a fellow by the name of Bill Krivit,
and we called BUI to find out how he would characterize Dr. El-
ders, and he said you are "the most forthright, forthcoming, and
helpful resident" that he has had for many years. The word ^forth-
right" is particularly important in that it is a personality trait that
you have obviously had all your life, and it is reflected in so many
things. "Plainspeaking'' might be another way to put it.
Plainspeaking is what seems to get too many people in trouble
these days, and that is perhaps one of the reasons that, at least
from my constituency so far, I had received as of the end of last
week 2,600-some telephone calls; 2,100 thought you were too
plainspeaking, and 500 supported you.

But because of my affection for "Doc" Koop and because of the
challenge that you are taking on, I have discovered if you look in
history that the Surgeon General is a fairly controversial,
plainspeaking, forthright kind of a position. I discovered that John
Adams appointed the first prototype Surgeon General, a doctor
from Philadelphia by the name of Benjamin Waterhouse, and he
got into all kinds of trouble with traditional medicine, because he
was doing things for kids like you are talking about doing now.

Tom Jefferson could tolerate him, even though he was a pain to
the predecessor of the American Medical Association, but the Presi-
dent who came after Tom Jefferson couldn't take the heat and fired
him.

There is a whole history of Surgeons General. Dr. Thomas Parrin
in the thirties was FDR's Surgeon General, and he sought to edu-

cate the American public about syphilis and gonorrhea and how
they are transmitted — and all that stuff we weren't supposed to
talk about in his day.

Dr. Leonard Sheel made the crucial decisions about the polio vac-
cine. Dr. Luther Terry launched the history-making study on the
connection between smoking and health — terribly controversial.
And obviously, one of our most forthright Surgeons General is, I
guess, our friend Dr. Koop. And as my friend from Kansas men-
tioned this morning, you think you've got it bad; this guy was
asked to come onboard in January 1981, and he didn't get sworn
in until January of 1982 out at Fort McNair. And if you just want
to read about 20 pages of this book, you'll find out why.

Dr. Elders. He sent me his book.

Senator Dureneerger. And I don't want to take this out on you,
but my friends in the American Public Health Association and my
friends in the American Medical Association and our friends in all
of these associations went after him. They called him incompetent.
That was the big charge against him, that he was incompetent to
handle his job. They didn't have the guts to say he didn't like what
he said when he was being plainspeaking and forthright, so they
called him incompetent. Ana one of these associations said, 'The
only reason we are here testifying in front of the Labor Committee
is because the man is incompetent"

Well, within a couple years, they were giving him awards for his
forthrightness and for his plainspeaking.

So clearly, one of the difficulties we have in American today is
sorting out our heroes ahead of time. And that is really the chal-
lenge that we continually get presented with here. You are obvi-
ously a hero to a lot of people who are here. On the other hand,
there are many people here who don't know you as well as I would
like you to get to know, like Dan Coats, who have a very, very dif-
ferent opinion. And then there are some people who are sort of in
between, because that's a place where a lot of us have to be, be-
cause we are responsible for making the policy, and you are respon-
sible for implementing it; but you are also responsible for calling
our attention to the things that we are not paying attention to.
That seems to be the history of the office of the Surgeon General.
But this is a difficult time in which to do it.

I once had an experience with Dr. Koop that just told me so
much about him. And I am taking the time to do this

Dr. Elders. I appreciate that.

Senator Durenberger. — because I am just guessing how you
might feel under the present circumstances with all of this public-
ity, and people down in Arkansas going through every, single little
record, and all that sort of thing. But this guy had it for a whole
year. They dragged him over to the House of Representatives, and
Henry Waxman was going to hang him up there because the public
health folks said, 'We don't want this guy around here."

But I'll tell you a little story that happened that I was involved
in with Dr. Koop a couple of my colleagues, right in the beginning
of the AIDS problem — and again, this is the man who did a lot to
call it to our attention.

We got into a discussion with a little group, and they were giving
him a hard time for talking about condoms, and sex education in

the schools, and things like that. We argued this issue for about
an hour and a half, and finally he said, "Look, we've got 100,000
priests and ministers in this country, but we've got only one Sur-
geon General, and at some point in time I have got to do what I
believe is the right thing to do." He does not change his view on
some of the behavior in this country. I walked out of a meeting
with 300 AIDS activists with him once, in which he said, "My job
is to give them some hope without condoning some of their behav-
ior that created that problem." Boy, what a tough job. What a
tough assignment.

Now, I have to believe that Bill Clinton knows you better than
any of the rest of us and that President Clinton has seen you in
action. And it is hard for us to prove by the record in Arkansas or
whatever it is, because we don't know Arkansas the way you do.
So when it gets right down to it, we have to believe that he knows
you well enough to know that you are able to do the kinds of things
that have to te done — not just because you want them done or
something like that, but because they need to be done for this
country.

I really do want to appeal to you, though, because the same issue
that hung him up for a year is still hanging us up, and because
you are a physician by profession, I want to give one little liner
from Hippocrates 2,000 years ago: "Healing is a matter of time, but
it is sometimes also a matter of opportunity."

We don't have a lot of time from what I can tell in this country.
You pointed that out with everything you said about what you see
in kids and what you see and don't see in families and the impact
of that. I don't think we've got a lot of time in this country, and
we need a lot of healing.

This morning, I think you added to your printed comments. You
were talking about drugs and alcohol, social problems, that these
are really psychosocial problems, I think, in our communities —
drugs, alcohol, violence, homicide, suicide, AIDS, teenage preg-
nancy— and then you added, "while we argue over whose values to
teach." I'd like you to explain that a little bit, because my sense
is that we do have to search for some values, and we have to try
to find the values that we all have in common rather than the
manifestations of those that seem to drive us apart all the time.
But by the same token — and you and I have discussed this — we
spend far too much time arguing about programs and pro-
grammatic solutions and categorizing people so we can put them in
a program, and authorize it and appropriate some money, and we
are hanging them up with regulations out there. And we have
talked about co-location of schools, clinics, and you talk about get-
ting us back to community. Maybe you can tell us how we can get
back to community. This place right here thinks it has an answer
to every community problem, but this is not a community. This is
not Hope or whatever little town you may have come from, or Lake
Wobegon, where I come from. The best we can do is enact one pol-
icy that applies to 39,000 different jurisdictions, and that doesn't
get down to the heart of these problems. So would you explain
what you meant by "while we all debate values," and what do you
think about how do we get at these community problems, and isn't
it maybe someplace other than right here in this room?

Dr. Elders. Yes. Well, Senator, obviously, if I had — well, even if
I had the magic answer, probably you'd have to be able to sell that
answer, even if it were right, to everybody out there. But I have
seen a real change in this country over the past 5 years, and I have
been to Minnesota, and I have been to Indiana, and I really feel
that now people are reaching out and beginning to think that we
can't keep trying to fix problems; we have got to reach out and pre-
vent problems. And whereas many people say, "I don't want that
teacher teaching my child; I want to teach him myself," I think
that may be fine for all the people sitting in this room, but we
know that there are a lot of people who are not sitting in this room,
who need schools to help them. We all want our children to do well.
Many people have told me, "Dr. Elders, let the church do it." My
brother, who is here, is a minister, but we know that 52 percent
of the children in America are unchurched; they don't go to any-
body's church. We know the children who go to church and who
have values really do well. But that's not true for all children, and
we have got to find a way to reach all children. And schools are
the only institution I know where all the children go. I feel that
if we are going to make education and primary preventive health
services equitable, Senator, the best place we've got is schools.
They are available, they are accessible to the children, they are af-
fordable— they are far cheaper than anything else — and they are
age-appropriate.

Certainly, in Arkansas, we can start arguing about the condom
issue and the abortion issue and everything else, rather than argu-
ing about how can we provide primary preventive health services
for all of our children; how can we educate them. And I feel the
only way we can do that is through schools. You know, having peo-
ple pop in on Thursday once a year to talk about drugs, Senator,
I don't feel will answer the problems. We have got to have it as a
part of the curriculum, and it has got to be taught every day, rein-
forced by what the teachers do, wnat they say, and it has got to
be reinforced in our churches, it has got to be reinforced by all the
people in our community. It has got to be a community commit-
ment for us to save our Nation. And Senator, from the things that
we have done in Arkansas, and I have seen from community com-
mitment— I saw the NBC affiliate give every PSA they had to teen
pregnancy in Arkansas. They won an Oscar or an Emmy, and they
were running around all over the country, picking up their awards
for what they had done. They did a wonderful iob of making people
in Arkansas aware of the problems. So I think once we make our
people aware of the problems, Senator, they will do it. Thank you.

Senator Durenberger. Thanks. I just got handed my note. I
really appreciate your response, and I appreciate your willingness
to share what is inside of you, not" just up here, as we've gotten to-
gether.

And I must, in my concluding minute or whatever-it is, just urge
on you, then, that your plainspeaking and your forthrightness be
inside this administration and across the board as well as outside
of it.

And I agree with you about schools, but at the rate we are going
in school reform, we aren't going anywhere; we aren't going to
make it — unless communities can take back those schools in some

way and make every one of them respond to the needs of that par-
ticular community. And school choice, and whatever else we may
call it, and outcome-based education— things that some of us really
believe in — but there are too many institutional barriers that keep
getting in the way of people making choice and giving people oppor-
tunities to do things differently.

The same thing is true with a really successful program like the
MCH block grant program.

Dr. Elders. Yes, sir; a very successful program.

Senator Durenberger. We have got to get more funding. I
mean, we are funding in the same condition we are with Pell
Grants on MCH, and it is one of the things that works so well. And
I have appealed to you, and I will just repeat that appeal, to ask
the President, who has been a Governor for the last 12 years, to
consider the possibility of having us federalize the approach to ac-
cess to medical services and let us in America take back our com-
munities and take back that responsibility away from all of the
Erograms that come out of this wonderful committee — let's take it
ack and start bringing the churches together, lef s bring the peo-
ple together, let's bring the volunteers together in the national
service and the community service and all the rest, and get off our
sort of categorical, programmatic horse, and let's get down and deal
with those problems the way they need to be dealt with.

Thank you.

Dr. Elders. Thank you, Senator.

The Chairman. We are going to have Senator Mikulski, Senator
WofFord, and then take a break, if that's agreeable.

Senator Mdxulski. Senator Kennedy, Senator Wofford has ap-

Frised me that he has to catch a plane to Pittsburgh. As you know,
only have to hop in a car to drive to Baltimore. So Fd be happy
to yield to Senator Wofford and then follow after him.

The Chairman. Pine.

Senator Wofford. Just for less than 5-minutes, Mr. Chairman.

The Chairman. Pine. Take your time.

Senator Wofford. It is good to see you again, Dr. Elders.

Dr. Elders. Thank you, Senator.

Senator Wofford. I appreciated everything you said before with
me, and today — and Senator Durenberger, thank you for arming
me well for my days in Pennsylvania with the words about Ben
Waterhouse, appointed by Thomas Jefferson, who was controver-
sial, too. I don't agree with all of Dr. Elders' statements in the past,
nor with very few other people's statements, and not necessarily al-
ways with all of my own statements of the past. [Laughter.] But
I find that to be the case almost always with people who are
straight-talking and independent-minded.

And as an advocate of health care reform night and day, I most
of all want a Surgeon General who will forcefully and passionately
carry the message of good health to the Nation. And from what we
have seen and heard from you and what you have done in your life,
I am sure you are going to be that kind of an Surgeon General.

I especially welcomed your commitment to prevention, your
statements that if confirmed, you will make your utmost goal the
education of our people, all of our people, on how to stay healthy.
As you recognizee! this morning, it is not enough to just reform the

health care system* we will never have a large enough budget to
address all the health care needs of our citizens if we do not start
thinking prevention and taking personal responsibility for our
lives— bravo.

I also appreciated your thoughts related to our national service
debate before the Senate, that young people need to be engaged in
other activities that lift their sights and give them adventure and
give them a chance to be productive and contribute.

So from everything I have heard today, I am encouraged you are
going to give the kind of leadership we need.

I would like to put my full statement in the record and also put
in the record the excellent long editorial in support of you by one
of our State's most principled and conservative newspapers, the
Greensburg Tribune Review, its editorial of July 21, 1993, asking
the Senate to confirm you, which I will do, too, when it comes be-
fore the Senate.

Thank you.

[The prepared statement of Senator Wofford follows:]

Prepared Statement of Senator Wofford

Dr. Elders comes before us well qualified to serve as Surgeon
General. She is a pediatrician, a public health official ana re-
searcher and writer on issues concerning child growth and develop-
ment who is recognized by her peers as one of our Nation's most
effective public health officials. Her list of supporters for this nomi-
nation include medical and public health professionals and associa-
tions that include former Surgeon General C. Everett Koop, the
American Medical Association, the National Medical Association,
the American Nurses Association, and the American Academy of
Pediatricians.

Dr. Elders has been criticized for some of the statements she has
made and positions she has taken as the Director of Arkansas
Health Department. I do not agree with all of Dr. Elders' positions
or statements, but I find this often to be the case with people who
are straight-talking and independent-minded. I particularly wel-
come Dr. Elders' commitment to prevention, and her statements
this morning that if confirmed she will make her "utmost goal^the
education of our people, all our people, on how to stay healthy." As
she recognized this morning; "it is not enough to just reform the
health care system. We will never have a large enough budget to
address all the health care needs of our citizens if we do not start
thinking prevention and taking personal responsibility for our
health.

As an advocate of health care reform I believe we need a Surgeon
General who will forcefully and passionately carry the message of
good health to the Nation. From what I have seen of Dr. Elders
and what I know of her background and achievements, I believe
she will be such a Surgeon General.

I would like to insert in the record an editorial in support of Dr.
Elders' nomination that appeared in the July 21, 1993 issue of the
Greensburg Tribune-Recora, one of Pennsylvania's principled con-
servative newspapers.

[The editorial referred to may be found in the appendix.]

The Chairman. Thank you very much.

Senator Wofford. Thank you. Senator Mikulski.

The Chairman. Senator Mikulski.

Senator Mikulskl Mr. Chairman, I am an enthusiastic sup-
porter of this nominee. My three criteria for support for a nomina-
tion are: competence in the field for which someone is nominated:
second, a longstanding history of service to the community; and
third, a vision for the future. I believe that Dr. Elders qualifies on
all three of those criteria.

I would like to have consent to have my statement which I was

f>ing to give at the beginning of the hearing included in the record,
know that the chairman will give me unanimous consent, so well
put that in. It is the only unanimous consent I get out of this hear-
ing. Dr. Elders.
The Chairman. Without objection.

[The prepared statement of Senators Mikulski and Wellstone fol-
low:]

Prepared Statement of Senator Mikulski

Mr. President, I am very pleased to express my full support for
the nomination of Dr. Joycelyn Elders to be Surgeon General of the
United States. I cannot think of a more qualified choice to protect
the health of the American public.

Mr. President, Dr. Elders has a long and distinguished record of
achievement that makes her very qualified to Decome the top
health official in the United States.

I am not sure how many people are aware that Dr. Elders career
in public health began as a commissioned officer in the U.S. Army.

She served her country for 4 years — staying 1 year beyond her
original obligation.

During those 4 years, she worked as a physical therapist at
Brooke Army Medical Center to try to make up for a shortage of
physical therapists at that time.

Dr. Elder's military service not only gave her the opportunity to
serve her country — it gave her an opportunity she otherwise
wouldn't have had — to go to medical school. Like so many Ameri-
cans at that time, she earned a GI bill. And that GI bill paid her
way through medical school.

Now that's what this country is all about. You help America and
America helps you. Dr. Elders helped veterans to get well and on
with their lives. And as a veteran — I would say our Veteran of the
Year — she went on to fight new wars against disease and poverty.

Dr. Elders had a vision of a future few women of her generation
could imagine: to be a doctor.

She told me when we spoke last week that it was during her
time in service to this country that going to medical school really
became a dream for her. And how lucky we are. Because it was in
medical school where she began to "focus on what has become her
great compassion and life's work — to improve the health of this Na-
tion's children.

That's why she became a pediatrician.

Dr. Elders is a special kind of pediatrician. She is a pediatrician
with perspective. While she treated one child at a time in her doc-
tor's office, she was developing a plan to help all children, espe-
cially poor and minority children be healthy.

She has shown that in her 20 year clinical practice career during
which she became one of the foremost experts on juvenile diabetes
and growth problems.

Dr. Elders has demonstrated over and over again a unique capac-
ity to combine new ideas for public health with an exceptional un-
derstanding of medicine.

But she doesn't stop with words and rhetoric. She turns these
ideas into action. She reaches out to children and families and pro-
vides them medical and preventive services where they are — and
where they are mostly likely to get them. And it is this that has
caused the most controversy.

Dr. Elders has won the strong backing of the community for her
efforts. She has built public health services from the ground up in
Arkansas — through the State and county departments of health,
the churches, the schools, organizations like the YMCAs, and even
with business — Arkansas will be a model for our Nation. She is
trusted because she knows what she is talking about.

Mr. President, many of my colleagues aren't aware that Dr. El-
ders is also an exceptional scholar. As a full professor of medicine
during 11 years at the University of Arkansas Medical School she
taught courses — practiced medicine- — and published over 150 arti-
cles on important developments in pediatrics.

Her programs to end teen pregnancy; reduce infant mortality;
improve the well-being of children and families are all based in

science.

Her victories fighting disease are too plentiful to recount.

But it is no wonder that President Clinton chose Dr. Elders when
he was Governor to head the Arkansas Department of Health. And
it is no wonder that President Clinton has asked Dr. Elders to
move to Washington to become this Nation's chief medical officer
as the Surgeon General of the United States.

Dr. Elder's experience as a scholar, innovator, and veteran will
serve well in her new role. Because Dr. Elders is a veteran of many
wars.

She started her career in health in the U.S. Armed Forces. She
spent countless years in the trenches fighting to improve the public
health of Arkansas. And now she will be bringing with her all that
experience and wisdom to serve our country once again.

Mr. President, I believe Dr. Elders has the proven ability to get
people to pull together to improve public health. I can think of no
more qualified candidate.

I urge my colleagues to give their support to this remarkable
nominee for Surgeon General.

Thank you.

Prepared Statement of Senator Wellstone

Mr. Chairman, I am proud to speak in support of Dr. Joycelyn
Elders for Surgeon General of the United States. Dr. Elders is just
what this Nation needs: a remarkable woman who has stared down
daunting odds, to make health services better for people.

Her decision to spend part of her pediatric internship at the Uni-
versity of Minnesota Hospital is only one example of her excellent
judgement. What impressed me so vividly, during our meeting a
few weeks ago, was her absolute commitment to working with com-

munities to develop health care programs that work. We discussed
the issue of domestic violence, an issue on which my wife. Sheila,
has done tremendous work. It is an issue that is still hard to talk
about and confront. It's, not a popular issue, one that brings people
to their feet in applause. It's one of those hidden epidemics, that
afflicts people who are often too powerless to defend themselves, let
alone to strike back. But Dr. Elders understood the importance of
confronting the issue of domestic violence, and supporting efforts
for change.

Similarly, she made me aware of a North Carolina study showing
that an overwhelming majority of that State's population support
school-based health centers for adolescents. There are always some
who will attack the kinds of school-based clinics that Dr. Elders
has championed. But Dr. Elders has always shown that she under-
stands her responsibility, as a powerful speaker, as a responsible
public official, to combat stereotypes if that's what it takes to pro-
tect our kids from sexually transmitted diseases, to reduce teenage
pregnancy, to get poor kids immunized. Arkansas is a poor State,
Mr. Chairman. No one could expect miracles from State health pro-
grams, especially during the Reagan years when State health budg-
ets were starved. But Dr. Elders took up the challenge. Under her
leadership, The Arkansas Campaign for Healthier Babies increased
the number of pregnant women who receive early and regular pre-
natal care by 17% in 2 years. Early childhood health screenings in-
creased from 4,000 to 45,000 in just 4 years. She developed pro-
grams that should have been in place long ago, to screen for sickle
cell disease and for cancer in low income women.

Minnesota has struggled for many years with the problem of at-
tracting providers to rural areas. Dr. Elders won grants that at-
tracted 17 physicians and 5 other health care providers in 1992, up
from 1.

This is a time of serious crisis in our country. At a time when
certain corners in the wealthy parts of our cities offer more high
tech medical equipment than entire nations, many Americans do
without the most basic services. A survey just released by the Com-
monwealth Fund found that 13% of women in this country fail to
receive the care they need in a given year, and among uninsured
women, more that a third fail to receive necessary care. One third
of all women did not have basic preventive health services in the
last year, including a Pap smear or a physical exam.

As we face the task of health care reform, we need a leader in
the Surgeon General's office who has a vision of where our health
care delivery system needs to be headed, and what our public
health services must accomplish. We have seen, from the notable
examples of C. Everett Koop, and more recently Antonia Novella,
that this is an office where a strong advocate can make a dif-
ference, and a strongadvocate of the people is needed.

I am in awe, Mr. Chair, of Dr. Joycelyn Elders accomplishments,
of her vision, her drive, and her commitment. The President could
not have chosen a better nominee. I pledge my full support for her
nomination, and look forward to the dynamic work we will be doing
together once she is confirmed.

Senator Mkulski. Dr. Elders, I know it is not easy to be a nomi-
nee. Unlike a physical exam, when you are presumed to be well,

and one is scrutinized to see if there is something that needs to
healed, often when there is a nominee in today's climate, there is
a presumption that something is wrong, and you have to prove
yourself to be okay.

I think that this hearing, you have proved yourself to be more
than okay. I want to congratulate you with an A" for effort in try-
ing to answer the questions with candor and forthrightness.

I have been impressed during the process of this hearing about
how actually informative it was; that there were many answers in
the Q and A that my colleagues have asked, and your answers, in
which I feel that I have learned something about public health,
something about the status of children, and many insights on how
to proceed.

I think when we can actually have hearings where we can learn
from the process, as well as learn about each other, should be the
model, and I believe we are going to learn for many years to come
from you.

I have two areas of questioning. One deals with the hat that I
wear as the chair of the Subcommittee on Aging on this committee,
and the other relates to Federal emergency management, another
responsibility I have in another committee.

As this Nation's Surgeon General, your job is not only to be the
top pediatrician of this country — and I support the goals and vision
that you articulated — but I want to also talk about the other popu-
lations in our society. In your Q and A about the Social Security
issue, you spoke about the issues related to Leona Elders. I believe
Mrs. Leona Elders has Alzheimer's; is that correct, Dr. Elders?
Dr. Elders. Yes, that's correct.

Senator Mkulskl My own father died of Alzheimer's. I know
the plight of families who have Alzheimer's. I believe in many of
the articles, for families enduring that situation, they call it the
"36-hour day"; am I correct?
Dr. Elders. There is a lot of truth to what you just said.
Senator Mkulski. Now, every female nominee seems to have
been getting a spill in the cinders or a bump around the issue of
caretaking, regardless of who has been the nominee. Caretaking
seems to be one of the fundamental issues in our society — where
do you find it? How do you pay for it? How do you make sure it
is good? Is "good" good enough? And not only for children, who
have been the focus of attention in I know your life's work, but now
you have provided caretaking for an elderly person, both financially
and personally. Your description of your own life touches me very
much. I know about those situations personally.

I wonder, from both your life experience and your experience in
public health, how would you envision yourself as the Surgeon
General on these issues of caretaking — do you have thoughts on it,
and what would be those insights, both from your own experience,
given with love, but difficult?

Dr. Elders. Senator, I feel very strongly about trying to provide
health care for our elderly in their own homes for as long as we
possibly can. Even for our health department — in fact, since I have
been health director, we haven't talked about that very much — but
we have expanded our health care from service of approximately $2
or $3 million to over $20 million, providing in-home health services

such that we can keep our elderly in their own homes. We provided
a lot of personal care. And from my own experience, Senator, I feel
that my sons have gained a lot from helping to care for their grand-
mother. That is not a problem for them to help care for their
grandmother, and they have learned from that experience. And
even though now, she really does not interact as much with us,
when she did, those were wonderful moments, and perhaps nothing
is better than to be able to have a grandmother that you come
home to and respect, because they remember when grandma took
them to Six Flags.

So in that sense, I feel that we should provide the best.

Senator MlKULSKl. So you feel the best place to care for anyone
is in his or her own home, and that it should be multigenerational?

Dr. Elders. Yes, I do.

Senator Mikulski. And in the programs that you have described
in Arkansas that essentially enabled and facilitated people to re-
main in their own homes or with their families, were you the archi-
tect of those programs; were you the prime mover, or did you in-
herit a legacy of another forward-thinking Arkansas public health
official?

Dr. ELDERS. Well, I think I was probably the mover to make it
grow, but it was started by a previous health director who hap-
pened to be 74 years old at the time that he left the health depart-
ment. But there is a young man there — he is still there — that's the
vision, Senator — I would like to say it happened while I was there,
but

Senator Mikulski. But you enhanced it. So, while people were
talking about you giving out condoms in school, you were also say-
ing that the elderly should get i.v. fluids in their own home, and
their meals-on-wheels, and things like that.

Dr. Elders. Oh, absolutely, Senator. And one of the groups that
helped me absolutely the most in Arkansas with the Arkansas leg-
islature was the AXRP. They would get up in the morning at 7:00
to go and fill the legislature, to make sure, carrying signs about
school-based clinics to support Dr. Elders.

Senator Mikulski. Oh, we know, we know.

Dr. Elders. So the walking elderly helped me fight for an in-
crease in the cigarette tax, Senator; they helped me fight for
school-based clinics; they helped me fight for many things.

Senator Mikulski. So you have helped to deal with this issue of
so-called multi or intergenerational conflict.

Dr. Elders. Well, I just feel that they have just been wonderful.

Senator Mikulski. Well, thank you for answering that line of
questions. Fd like to now move to another area.
^ Dr. Elders, I chair the subcommittee on appropriations that
funds Federal emergency management, and my questions will go
exactly to public health issues, if I might. Last weekend, I toured
the flood areas with the President and the team, and met with
some of the Public Health Commissioned Officers, by the way, to
talk with them. Here is my question. As the Surgeon General of
the United States, and your heading up the Commissioned Corps,
as Senator Pell raised, could you tell me what in your mind would
be the issues around public health and what you will be doing if
confirmed quickly to meet the flood relief victims, and what do you

see the public health role, and what do you see the Surgeon Gen-
eral's role in responding to this great tragedy where some have lost
their lives, some have lost their communities, some have lost their
livelihoods, and are now faced with stench, disease, and more rain?

Dr. Elders. Senator, it is the responsibility of the Public Health
Service, a part of the Commissioned Corps, under both the Surgeon
General and Dr. Lee — I guess I am more personnel — to respond
quickly, immediately, and to take care of the problem; make sure
people have safe drinking water; make sure we are abiding by ap-
propriate public health problems; make sure that we can, if we
have to, transport in a hospital.

So we are the first responders to emergencies such as that,
whether they are floods, whether they are hurricanes or large
spills; whenever there is a major tragedy in our country. I feel that
we have to respond to people in the time of need. Senator, if we
can't respond in the time of need, well, then, when can we respond?
That is the responsibility and one of the functions of the Commis-
sioned Corps.

Senator Mikulski. Dr. Elders, you have been one of the top pub-
lic health officers of a State where one of their primary hazards
has been flooding. This is a situation that has befallen the State
of Arkansas on many sad occasions. Have you led the public health
efforts to respond to those? When we were in St. Louis, MO with
the President and the Governors and so on, they talked about ev-
erything from the need for immunizations against diseases ranging
all the way through to the mental health problems as people face
the horrendous collapse of their community. Have you actually led
efforts in that? Have you been a public health person who has done
that?

Dr. Elders. Yes. That is handled out of my office, in fact. We
have the response book, and all agencies — we meet, we all have our
orders, we all know what we are supposed to do. We know who is
going to call the Federal health. So that is something that

Senator Mdxulski. Do I have another minute or two, Mr. Chair-
man?

The Chairman. Yes.

Senator Mikulski. Could you tell us what you did to respond to
the flooding in Arkansas? I mean, you look like the kind of lady
who would just jump in a jeep and get out there.

Dr. ELDERS. Well, I have been very fortunate, Senator, that we
haven't had a flood. But we have had

Senator Mikulskl Well, hopefully, if you become Surgeon Gen-
eral, maybe we won't have another one.

Dr. Elders. We did have a terrible problem in response to a cri-
sis down at Pine Bluff when there was a really very major toxic
spill that might have required evacuating an entire town of about
40,000 or 50,000 people. But we immediately have, obviously, our
environmental people, we have our nurses, we have our doctors, we
have our physicists, and these people, the minute they are called,
have to immediately go out and begin to address all of the prob-
lems— the police and so on. And we man also the radio, the commu-
nication system. And we spent the whole week working on how
would we respond to that earthquake that they thought they were

going to have down in Arkansas some months ago. But the entire
health department is involved.

Senator Mikulski. Did you design the plans and oversee the
management?

Dr. Elders. I did not design the plans, but I was a part, and I
worked with the plan and the person who was always there and
represented me, who is one of our physicists who is over our radio-
active waste disposal

Senator Mikulski. Well, actually, that is one of your jobs as the
Surgeon General, I believe. According to the job description, you're
supposed to review the Department of Defense plans for transpor-
tation, open testing, and disposal of lethal chemicals and biological
agents and recommend

Dr. Elders. That's correct, and I have had 5V2 years' worth of
how we need to deal with those problems, Senator.

Senator MncuLSKi. So you as the Surgeon General of the United
States feel that in addition to really wanting to focus a lot on the
compelling needs of our children, you also see your job as broader
than that, and you feel that you, because of your experiences, have
the competency and the long history in that; is that right?

Dr. Elders. I certainly do, Senator. I feel that I have a real com-
mitment, certainly, to our elderly, and I feel they are very aware
of that. And I have a real commitment to our environment. I feel
so strongly that the greatest gains we have made in public health
are really related to safe drinking water. To me, that is a big re-
sponsibility, to make sure that it is not contaminated. I feel that
we must protect our environment at all costs.

Senator Mdculski. Thank you.

Mr. Chairman, there are many more questions I could ask, but
I think Dr. Elders now has certainly answered my questions, and

I look forward to further Q and A from other colleagues.
The Chairman. Thank you very much.

Senator Bingaman, we are glad to have you. I know you have
been at Armed Services, where I am also a member, and I regret
being unable to attend those meetings today. We know you have
been necessarily absent, but we welcome you back now.

Senator Bingaman. Thank you very much, Mr. Chairman.

Dr. Elders, it is a pleasure to be nere with you. I really wanted
to mainly congratulate you on your nomination and wish you well
in this new position, which I am sure you will be confirmed in as
soon as the Senate votes on the issue.

I do think that you have a rare talent for forcing us to focus on
the real world we live in and not the world that we wish we lived
in, and that is something we desperately need here in the Nation's
Capital and throughout the country. So I welcome your ascension
to this position.

Let me cite one issue that is of particular interest in my State,
and I am sure it is one that you don't get asked about that often.
The Federal Government, of course, in the public health system,
which you would be the primary spokesperson for, the Federal Gov-
ernment has the main responsibility for the health of the Native
American people. And we have had a series of particular health
problems that have afflicted that population. One is diabetes. Type

II diabetes, for example, is very prevalent on many of the Indian

reservations in my State and throughout the country. Alcoholism
is a serious problem.

I don't know if you have any comments you could give us today
on your thoughts about how we could do a better job of meeting our
responsibility for providing health care for that group of Americans
as well as the rest of us.

Dr. Elders. Senator, I have been to your State on several occa-
sions; in fact, one when we were reviewing a large NIH grant relat-
ed to looking at diabetes in Native Americans. I very much support
providing the kind of health care that is, if you will, tailored to fit
the needs of our Native Americans. We know that with appropriate
diet and getting started early, early education, weight control, that
we might be able to at least, if not reduce it, prolong the time be-
fore onset of diabetes.

So I would certainly hope that we would continue to start pro-
grams early such that we could address that. As you know, 40 per-
cent of the Commissioned Corps is assigned to the Indian Health
Service. Obviously, that is a large part of what the Commissioned
Corps does is making sure that we serve in areas that are terribly
underserved and need more services*

I know that we are not providing adequate health services in
many of the underserved areas, including your State, certainly
even including my State, but we will continue to try to address
those issues.

And I know that the problem of alcoholism is a real problem, es-
pecially for pregnant women, and the development of fetal alcohol
syndrome, where children who will often live with long-term per-
manent handicaps. So it really is a major issue where I feel that
we have got to start looking into better ways than we presently
have to address those issues.

I wish I knew how to tell you this is how to do it.

Senator Bingaman. Let me ask you about one other public health
problem which I see in my State, and that relates to our Hispanic
community. Historically, the Hispanic population of my State has
not had some of the same health problems that the rest of our pop-
ulation has had. One example is lung cancer. We have not had
nearly the incidence of lung cancer in the Hispanic community that
we have had in the rest of our population because the incidence of
smoking has been less. We have seen a very concerted effort by to-
bacco companies in recent years to target the Hispanic community
and increase the incidence of smoking, seeing that as a very lucra-
tive market to be developed.

These are issues which I hope you will be able to speak out on
in your new position and provide leadership on, and I am sure,
based on your previous experience, that you will not shrink from
speaking out on them. So I'd just cite that for you and ask if you
have any comment.

Dr. Elders. Senator, I appreciate what you have just said, and
I feel that we must speak out against tobacco very forcibly, and we
must do it early. The tobacco industry really is always recruiting
bright young people into beginning smoking early, to keep their in-
dustry going. So I will be speaking out against tobacco.

Senator Bingaman. Mr. Chairman, I could go on for some period
with questions, but I think Dr. Elders has been very patient. I ap-

predate the chance to support her nomination, and I commend you
forgoing forward with the hearing today.

The Chairman. Dr. Elders, we are in kind of a unique situation
where we may be able to wind up.

Dr. Elders. Fm doing fine, Senator.

The Chairman. And without wanting to "disturb the particles,"
as Winston Churchill once said, if you feel comfortable, we could
go on, rather than taking a break and risking other points.

Dr. Elders. I feel fine, Senator.

The Chairman. We may not; if it is inevitable that we can't, well
take a break shortly.

Senator Kassebaum.

Senator Kassebaum. I have one more, prompted a bit by Senator
Metzenbaum's comments about right wing groups having opposi-
tion.

Dr. Elders, you and I talked a bit about the lightning rod — and
I think the pins are marvelous — but Senator Durenberger and Sen-
ator Wofford spoke, too, about comments that sometimes, in their
forthrightness and our understanding of them, it would help us to
know your concerns and why you .said them. But on the other
hand, I think it goes beyond that. Sometimes comments can just
be a bit off-putting when you really want them to bring people to-
gether and may cause them to stand aside.

Let me ask — and I do this at some risk because, as Senator
Wofford said, we all say things that are either taken out of context
or we wish we hadn't said — but I would like to give you examples
of some that have been in the press and have caused, I think, some
concern.

One is: "I tell every girl that when she goes out on a date, put
a condom in her purse." And: "We taught them what to do in the
front seat of a car; now it is time to teach them what to do in the
back seat."

There is the reality of the times we are in — but I think again,
it isn't just right wing groups that might have some concern about
those comments; it is others who would say, "Oh, gosh, is that what
I look at for my granddaughter?" and think that this is what real-
istically is there. Again, on providing condoms in the schools, you
said: 'Well, we aren't going to put them on their lunch trays," but
that yes, you felt that was important. And I suppose the one that
has been quoted the most often is: "We would like for the right to
life, anti-choice groups to really get over their love affairs with the
fetus and start supporting children."

I do not raise these to cause any discomfort. On the other hand,
I do raise them because I think that as the Surgeon General, and
to address the causes that you care about and that we care about,
whether it is Senator Coats or Senator Kennedy or Senator Mikul-
ski or myself, we have to bring people together, and we have to
make them feel comfortable, not distant.

And I know that you feel — and it may be right, and Senator
Durenberger alluded to this — that you have to kind of get people's
attention and shock them into a realization of what needs to be
done. But it has to take a certain balancing, I would suggest, and
I wonder how you would answer that.

Dr. Elders. I would agree with you, Senator Kassebaum. I think
we all would like to bring people together and have them work to-
gether. And when those statements are just statements out there,
out of the context of a whole speech, sometimes I think the flavor-
ing becomes very different

When I made the comment, for instance, in regard to the pros-
titutes and Norplant, well, taken out of context — in the context
that I was answering it, they were asking if I would support Fed-
eral programs or programs to pay for Norplant for drug-addicted
women who were prostitutes. And I still feel that rather than them
having drug-addicted babies, I still would. But just to say that I
would just be doing that so they could go out and have babies or
something — obviously, I don't support that. I am not about that.

In regard to the front seat and the back seat comment, I think
that as we teach our children driver's education — almost every
school in Arkansas has some type of driver's education — we teach
them to not drink and drive; we teach them to always wear their
seatbelts — and we teach them sex education, to be responsible.

And Senator, I believe that abstinence — I feel as much or more
than anybody — I certainly feel that that is what I have taught my
children. Every parent I know, I feel, supports and teaches absti-
nence. Every preacher I know supports and teaches abstinence. But
we know that sometimes they are not abstinent. But the thing that
I was really trying to say was that we want them to be responsible.
If you can't be abstinent, I want you to be responsible. If it hap-
pens, certainly, use a condom; don t take the risk of AIDS or sexu-
ally-transmitted disease or pregnancy.

Everybody is excited about abortion. I have never been about
abortion. I think we discussed that issue. I am about preventing
unplanned pregnancies. And I think we know that if we could pre-
vent the pregnancy, then abortion becomes a nonissue.

So what I was really saying was that we need to teach our chil-
dren more than just No. We need to teach them how to say no,
and we need to teach them that if they get into problems, to be re-
sponsible, to make a responsible decisions. I think that was what
I meant by that statement, and I think in the context of the whole
speech that I made, I think most people would agree that that was
how I meant that statement. So that's what I meant.

And in regard to the condoms in the purse, again, I was probably
caught up in the moment. I was speaking to a high school group
that was having a prom about a week or two later, and we had
spent a whole hour with them asking questions and talking. And
I did say — Fm not going to deny it — I did say that I feel that they
should never go out on a date with somebody that they liked — and
I did have that statement in there, too — unless they had a condom
in their purse.

What I was really saying to the girls was don't depend on the
young man to say, "I don't have one. You make sure, that you have
one. And I guess I still don't really disagree with that. I don't want
them ever having to need them. I just don't want any of them. But
I want them to be responsible.

Senator Kassebaum. You have been endorsed by the Arkansas
PTA, I believe it was stated. Do you work quite a bit with the par-
ent groups and with the schools?

Dr. Elders. Yes, I do, Senator.

Senator Kassebauwl It seems to me again an important avenue
that just can't be overlooked. And it goes back to my opening com-
ments about the changes in generations and the changes in influ-
ences, like television, and I agree so much with your comments on
that. It is the sexual innuendos that we hear today in our advertis-
ing and so forth that I think are all part and parcel of the bigger
picture.

Dr. Elders. Yes.

Senator Kassebaum. But how you address it, again, as the
spokesperson for our Nation's health, becomes the question, and I
think that is terribly important. As I said, it is a great opportunity
because it is obviously a major problem that we have. But how it
is done, though, in order to get the broadest audience possible to
support it, will probably require a little bedside manner as well as
the thunderbolt.

Thank you very much.

Dr. Elders. Thanks, Senator.

The Chairman. Thank you.

Senator Coats.

Senator Coats. Thank you, Mr. Chairman.

Even though he is no longer here, I want to thank my colleague,
Senator Durenberger, for saying some very nice things about me —
I hope they are true.

Dr. Elders. Senator, I thought you were very nice when I came
to visit you, so I have been saying nice things about you, too.
[Laughter.]

Senator Coats. I was starting to think I might be getting a bad
rap. Whatever the case, I hope you can still say that after I am
done with this round of questioning.

Dr. Elders. Go right ahead.

Senator Coats. It is not easy to talk about these financial ques-
tions. In fact, I respect an individual's right to privacy and, from
one standpoint, regret that we have to ask these questions. But I
think they need to be asked only because many have written and
alleged that there are potential conflicts of interest. And I would
think you would want those resolved, and we need to have those
resolved. If there are conflicts of interest, then that is a matter that
the committee needs to take into consideration in terms of your
nomination.

I understood your reluctance to release some of your tax forms,
which is why I suggested a closed hearing so that we could discuss
these candidly without you having to do it on nationwide television.
But you and the chairman said no, you are more than willing to
do this on a public basis, so while the questions are a little bit dif-
ficult, you have chosen to do so, and I want to just take a small
amount of time here to pursue a couple of questions that I did not
get to in my first round.

This whole matter of caretakers and domestic help and paying
their taxes, no one really knew that was a problem until we had
some Attorney General nominees, and it suddenly became a very
explosive political issue. And it is probably not of much comfort to
Zoe Baird or Kimba Wood that we are now saying, oh, well, this
doesn't really matter. It certainly matters to them. Whether it was

an appropriate question or not, it was a determining factor in the
fact that they are now back in the private sector and did not be-
come Attorney General.

So it is an issue, and I think questions have been raised, and you
have answered many of my questions, but I just wanted to clarify
a couple of points.

You stated that you and your husband have paid for the care out
of a joint account. Then in response I believe to Senator Kennedy's
questions, you indicated that actually, the funds for that were your
mother-in-law's funds which were placed in your husband's and
your joint account and then paid back out. Am I correct on that?

Dr. Elders. That is correct.

Senator Coats. Now, this individual, Audrey Ruffin, who pro-
vided the care for your mother, was she connected in some way
with the Mercy Nursing Home?

Dr. Elders. Yes.

Senator Coats. What was that connection?

Dr. Elders. She was the daughter of the former owner of the
nursing home before it was sold.

Senator Coats. All right. And I believe your financial disclosure
form filed with the State of Arkansas indicated that you had a fi-
nancial interest in that nursing home; is that correct?

Dr. Elders. My financial interest was a salary, Senator, for serv-
ing— I was providing medical care at that nursing home. I had no
financial interest in that nursing home.

Senator Coats. All right. So your financial— whatever you'd call
it, financial interest, or whatever — the financial connection with
the Mercy Nursing Home was that you were providing nursing
care

Dr. Elders. Yes.

Senator Coats. — to the nursing home?

Dr. ELDERS. No. Senator, I am a physician. I was providing medi-
cal care.

Senator Coats. Well, I'm sorry. I misspoke. You were providing
medical care

Dr. Elders. That's correct.

Senator Coats. — to patient in that nursing home.

Dr. Elders. Yes.

Senator Coats. And you did so while you were State health di-
rector for the State of Arkansas?

Dr. Elders. Probably, yes, for 9 months or so. It closed not too
long after I become — well, months after I became health director.

Senator Coats. All right. The Washington Post said you served
as medical director of the nursing home for 18 years.

Dr. Elders. Yes, that's correct.

Senator Coats. I don't understand the differences. Didn't you
just say 9 months?

Dr. Elders. But I wasn't the health director for 18 years.

Senator Coats. All right. You served as medical director for 18
years at the Mercy Nursing Home.

Dr. ELDERS. That's correct.

Senator Coats. And did you receive a salary during that 18
years?

Dr. Elders. Yes.

Senator Coats. All right. I am still a little bit confused about the
9 months.

Dr. Elders. After I became health- director, the nursing home
closed, I think, the following year.

Senator COATS. Fm sorry. After you became health director for
the State of Arkansas, the nursing home closed.

Dr. Elders. Yes.

Senator Coats. All right. And then you terminated, obviously,
your service there.

Dr. Elders. Yes.

Senator Coats. Now, in 1990, we are not able to get hold of—
I believe you are required under Arkansas law to file financial dis-
closure statements— but we cannot find your 1990 financial disclo-
sure statement.

Dr. Elders. I can't find it, either.

Senator Coats. So it is lost?

Dr. Elders. I assume it is lost. Senator. My secretary has looked
for it; the secretary of the State nas looked for it. We don't remem-
ber them ever asking about it again, and I can't remember — I usu-
ally file them every year.

Senator Coats. Whom is it filed with in the State of Arkansas —
the secretary of State?

Dr. Elders. The secretary of State.

Senator Coats. And they have no record of it?

Dr. Elders. No. That's where we went for the files, and they
said that they couldn't find it. I don't know

Senator Coats. Is it possible it wasn't filed?

Dr. Elders. That is possible, Senator, but I really can't remem-
ber. And it is not a complicated form. Nothing changed on it. So

Senator Coats. But there is no copy, no record?

Dr. Elders. Well, we can't find it, Senator. We looked.

Senator Coats. And that's the same period in which the nursing
home became insolvent— did it become insolvent?

Dr. Elders. Fm not sure it became insolvent The person who
owned the nursing home sold her right to have a nursing home,
and all of the patients were subsequently moved, and someone else
used her — it's called something; I can't remember — to keep from
overbuilding in Arkansas, there has to be a certificate of need, and
the certificate of need was sold. So all the patients were moved, so
there was no nursing home.

Senator Coats. All right. If I could, let me follow up on Senator
Kassebaum's points that she was going to make, because I agree
with her, and I think you did, too, in that the Surgeon General
plays kind of a unique role in our Nation. The influence of the Sur-
geon General is largely persuasion, and generally, what I think the
Surgeon General tries to do is educate the public as to public
health hazards and healthy practices. And for the most part, I
think its greatest power, I guess, has been moral persuasion, moral
leadership, trying to build a consensus. And you indicated that you
thought that that was important.

There are a number of issues that you have spoken out on, and
Senator Kassebaum raised some quotes on a couple of them, where
I think it raises into question whether it is consensus building or

dividing. You know, we on this panel have fundamental disagree-
ments over the issue of abortion. I think our challenge is to discuss
those disagreements in a serious but civil way without trying to at-
tack motives.

When we talk about contraceptives, and whether that is the best
way to approach the problem of teen pregnancy, there are many of
us who are concerned that just promoting condoms as a solution to
the problem can actually promote promiscuity, and you can see
how easily statements can be taken out of context.

Dr. Elders. Senator, if I might say something, if I might inter-
rupt you for just a moment.

Senator Coats. Sure.

Dr. Elders. One of the things in regard to condoms — I think if
they would read Arkansas papers very carefully, they would also
find a statement that I said that I am a physician, and if I thought
just passing out condoms would solve the teenage pregnancy prob-
lem, I would go out on the Mall — and I am a doctor, and I can —
and iust pass out condoms. But I know that that will not solve the
problem. So I am not about just passing out condoms. That has
never been what I have been about..

Senator, in some of our very poor areas, we also had young peo-
ple trying to help to protect themselves who could not afford or
could not get to the store or did not have condoms, Senator, who
were using saran wrap for condoms to try to protect themselves.

So what I have been about, and I always say every time, I am
about six things. I have never been about any single thing. And I
think you and I discussed those — early childhood education, com-
prehensive health education, parenting education, educating our
parents, teaching our young men to be responsible, comprehensive
school-based health services, and providing programs that offer
children hope. And I think we need all of those; no single one of
those would solve the problem.

Senator Coats. Well, I appreciate you saying that, and I also ap-
preciated your comments regarding abstinence. I think, unfortu-
nately, whatever you have said in that regard relative to address-
ing the very serious problem of unwanted pregnancies has not been
highlighted or reported or given primary emphasis — at least in the
press, it has not. But all the emphasis has been on condoms as the
primary preventive. And I think that discourages several of us for
a couple of reasons.

One, I think it totally avoids the moral question. Second, we
know that condoms are not failsafe, and we know that sexually-
transmitted diseases can pass through condoms. We know that
there is a failure rate of 10 to 15 percent, or whatever — Planned
Parenthood says 15.7 percent in their latest missive, and much,
much higher for group-specific failure areas. Other groups say it is
higher, other groups say it is lower. We know they are not failsafe.

We know that the AIDS virus can be passed through condoms,
and we know that they break, and we know that they slip, and we
know that they are not properly used. So the last thing we want
to do is leave a message that all you've got to do is use condoms,
and you are safe. You may be safer, but you are not safe.

I think an awful lot of young people in our society today think
that, oh, the solution to AIDS, STD, pregnancy is condoms. I am

not sure we are really educating them on the fact that we've got
a lot of pregnant women and a lot of people with STD, various
types of sexually-transmitted diseases, and people with AIDS who
used condoms and thought that they were protected.

So I was happy to hear you say that abstinence is important, and
it really ought to be a primary message. In fact, if you are telling
a young girl if you really want to be safe — and I am just talking
from the medical standpoint now, not the moral standpoint — but 2*
you really want to be safe, don't count on condoms.

So perhaps it has been misstated, or perhaps only those quotes
about condoms are the ones that have been quoted, but I was
happy to hear you say that about abstinence. And you used the ex-
amples of we teach

Dr. Elders. Senator, may I respond to the abstinence problem?

Senator Coats. Sure.

Dr. ELDERS. I think that we all support abstinence, we all want
abstinence. I know that that is what I feel we should all be about.
And if you find out the magic bullet on how to be abstinent, what
I want more than anything else as your Surgeon General is to real-
ly be able to reduce or eradicate AIDS, sexually-transmitted dis-
ease, and to make every child a planned, wanted child. And if I
knew how to do that, listen, whatever it took is exactly what I
would do.

We know that condoms are not 100 percent. The only thing that
is 100 percent is abstinence. But we know that many of our chil-
dren are not being abstinent. And I want you to know that given
a choice between a young woman coming in and saying, "I am preg-
nant," and whether or not she uses contraceptives, most mothers
I know would get up at midnight and go out and buy them for their
children themselves; no mother wants to hear that her child is
pregnant. And I think we always get bound up in abortion, Sen-
ator, but the real issue is preventing the pregnancy. Then abortion
becomes a nonissue.

I know that nothing is failure-proof, but I feel that we have to
protect, and we use the best resources we've got. I know you have
insurance on your home, I know you have insurance on your car,
but you would not go out and burn your house down or wreck your
car just to collect the insurance. And that is why I feel that we
have to look at condoms as a protective measure. We don't fight
wars, we don't make guns to kill people. We have guns to protect
our country.

So it's the best we've got. While it is imperfect, it is the best
we've got.

Senator Coats. Well, I too understand the realities of what we
are dealing with with young people today, and the messages that
are shouting at them to go ahead and do it; everybody else is. But
in your position as Surgeon General, you really will have an oppor-
tunity to exert moral leadership as well as practical public health
directives. I know your brother does that from the pulpit. I know
many, many pastors do that from the pulpit. I know many kids
don't go to church and listen to those messages. And while they
might not go to your brothers church, they might listen to the Sur-
geon General on that subject. So I hope you are eloquent on the
subject of abstinence, knowing that that is a message that not ev-

eryone is going to heed — but maybe some will, and maybe some of
those who will will avoid the tragic, consequences that come from
even failure of preventive measures.

Now, in that vein, I wonder if I could just quote to you a couple
of other quotes and give you the opportunity to say, "Well, that's
not what I said," or maybe it's in a different context, or whatever,
because I did see these as divisive, and I think if we are agreed
that consensus building is important and educating is important,
we ought to make sure that all of us — the people on this side of
the dais as well as that side of the dais — try to avoid those state-
ments that get to motives or are misconstrued or are seen as polar-
izing and divisive.

For instance, you are quoted again in the Washington Post as
saying: "Pro-lifers are very religious non-Christians. Yes, they love
little Babies as long as they are in somebody else's uterus." You are
quoted as saying: Most of our society believes that a baby is God's
just punishment for fornication. I am going to keep using him to
grind in that punishment to you."

Did you say that, and do you really believe that?

Dr. Elders. The first statement, Senator, I certainly did make,
but — I'm sorry, would you mind — my brain must dying off

Senator Coats. "Pro-lifers are very religious non-Christians."

Dr. Elders. All right. Let me tell you why I said — and I don't
think I ever— "pro-lifers" is not a statement that I use very often,
Senator, so if that was the way it was worded, that's not what I
said. I really said— I think it's more likely that I said "the right to
life is really the"— what I probably would have said— "very reli-
gious non-Christian right." , u

The reason why I would say "very religious non-Christian right,
Senator, is that in Arkansas— I don't know what they do in your
State— but what they do is they fight against health education,
they fight against welfare, they fight against Medicaid, but they al-
ways want to have the children born, but they do not want to sup-
port children after they are here. And that was probably where the
^ove affair with the fetus" may have come in, because I looked on
it as an affair, that is, a short-term commitment; whereas with
children, that's forever. That is a very long-term commitment. And
in my State, I have not seen them out working for programs to
help poor mothers. And if we had a society where everybody was
provided health care, a decent place to live, and an adequate edu-
cation, then Senator, we would be taking care of all people. But in
Arkansas, in my State, I don't see these kinds of commitments.

Senator Coats. Well, all right. The Los Angeles Times quoted
you as saying: TVlost of our society believes a baby is God's just
punishment for fornication." Do you really believe most of our soci-
ety believes that? -

Dr. Elders. I would have never said "most of our society. I
would have been restricting it probably to a very narrow group.

Senator Coats. But you are quoted as saying "most of our soci-

Dr. Elders. Senator, if I would talk about the number of times
that I have been misquoted— and I am sure maybe you have not
been misquoted — but I would say that

Senator Coats. OK So you didn't

Dr. Elders. But I don't mind

Senator Coats. You didn't say that. The Los Angeles Times
is

Dr. Elders. I probably didn't say "most of our society." But I did
say that there are people in our society who look at having a baby,
a pregnancy, as just punishment for fornication.

Senator Coats. "God's just punishment for fornication."

Dr. ELDERS. Well, I might have said "God's just punishment." All
right.

Senator Coats. Because in the Berkeley Law Journal in an arti-
cle you wrote

Dr. Elders. Thaf s right.

Senator Coats. — and this one, I assume, was not misquoted —
"We have refused to make a commitment to solving the crisis of
teenage motherhood because we view pregnancy as just punish-
ment for the sin of premarital sex."

Dr. Elders. I did say that.

Senator Coats. And do you believe that?

Dr. ELDERS. I wrote it, and I did say it, yes, sir.

Senator Coats. So in essence, the Los Angeles Times, maybe a
word is off here or there, but that's what you were trying to say,
I assume.

Dr. Elders. What I wrote, Senator, was — that was why I was
questioning — I guess there are certain things I don't recognize as
what I said, but what you read out of the Berkeley Law Journal
is exactly what I meant.

Senator Coats. Well, Tm not about to get into the theological
correctness or incorrectness of that conclusion. The point I am try-
ing to make is that to many people whose faith is very important
to them, they view that as a very divisive, radicalizing, polarizing
statement, and "those are fighting words."

Dr. ELDERS. Senator, my iaith is very important to me, too.

Senator Coats. Let me just turn to one other area of quotes, and
I can probably stop at that. You said: "In the 17 years that abortion
has been legal nationwide, it has had an important and positive ef-
fect on public health." Do you really believe abortion has had a
positive public health effect? I mean, many of us see that as a trag-
edy. We see teen pregnancy as a tragedy.

Dr. Elders. I see teen pregnancy as a tragedy. I see abortion as
a tragedy. And Senator, my whole effort — tine only efforts I have
made and will continue to make — is really to try to avoid teenage
pregnancy. I feel that if we stop talking about abortion and start
putting our efforts on how do we prevent unplanned pregnancies,
we can begin to make real progress in our society.

Senator Coats. I raise that because you had also indicated before
this committee in your testimony in 1990 on the Freedom of Choice
Act, you said: "Abortion has reduced the number of children af-
flicted with severe defects. The number of Down's Syndrome in-
fants in Washington State in 1976 was 64 percent lower than it
would have been without legal abortion," to which the Down's Syn-
drome Congress replied: "Does this mean Dr. Elders feels children
with Down's Syndrome are not worthy of life in our society?"

Dr. Elders. Absolutely not, Senator. The statement was in fact
a statement of fact. The number is a fact. But I have had many

patients that I have cared for with Down's Syndrome. My favorite
uncle, my nephew, has Down's Syndrome. He is presently 20-plus
years old'— a wonderful, lovable child.

I feel, Senator — I think we were talking about the Freedom of
Choice Act when I spoke — I feel that people should be able to make
that choice. I do not feel that I know enough about other people's
lives to make that choice for them. I am not good enough to make
that choice, and Senator, I don't feel that I love enough to make
that choice. I feel that that is a choice that they have to make be-
tween themselves, their significant other, and their God. It should
not be made by me.

Senator Coats. Well, having just said that, let me ask you this,
then. In an interview with Bryant Gumbel on December 30, 1992,
you said, "If you wanted to keep kids healthy, you had no choice
but to take command of their sexuality at the first sign of puberty.
I would tell them," you said, "you are going to have two good ba-
bies, and I'm going to decide when you're going to have them."

How does that square with what you just said about not being
in a position to make a choice?

Dr. Eldeks. Senator, I know those two things were never said
together in an interview with anybody. About the "two good ba-
bies," we were talking about children with diabetes. I am a pedi-
atric endocrinologist. I took care of young children with diabetes,
and I did not want them involved, Senator, in having babies before
they were ready to have babies. I wanted them to be in good con-
trol, and I wanted them to have very healthy babies. So, when they
began puberty, with their parents sitting in the room — and there
were probably 500 parents all over Arkansas who would come — we
talked about the things that would go on and what would happen.
And every time I ever talked to any parent of a child who had dia-
betes, all I saw was sitting in the chair, nodding. And some of
them, when they were going to get married, we talked about it; we
would make sure their hemoglobin A-l-Cs were right; we would
sometimes change them to put them on a pump. So I very strongly
felt that I wanted them to have two good, healthy babies. We are
not talking about abortions. We are talking about pregnancy.

Senator Coats. Well, I think it is important that you have an op-
portunity to clarify that. I mean, it is quoted by some pretty rep-
utable sources — New York Times, Washington Post, L.A. Times.

Dr. Elders. And Bryant Gumbel never talked with me of some-
thing of that sort.

Senator Coats. I just have one more area, Mr. Chairman, unless
you want to—

The Chairman. I would just ask regarding diabetes, the inci-
dence of high-risk pregnancy for diabetics is much higher; is that
correct?

Dr. Elders. Oh, yes, sir.

The Chairman. I mean, this is a medical phenomenon, the dif-
ficulties diabetics face when they have children.

Dr. Elders. Yes, absolutely. Any woman, especially those who
have juvenile diabetes, has a far higher risk of having a child who
is born — they may be born big, but they are premature. They have
a far greater risk of having congenital malformation if they are not
well-controlled at the time of their pregnancy, and they have a far

greater difficulty with their pregnancy. So we have really tried to
plan very carefully, plan the pregnancy such that they would be in
control and that we would try to Keep them very

The Chairman. So that they have the best opportunity to have
a healthy baby.

Dr. Elders. Absolutely.

Senator Coats. One last issue — this whole question of defective
condoms. And I know that we touched on it earlier, but Fd like to
just ask a couple of questions about that.

The condoms, as I understand it, were purchased from Ansel,
who sold them under the brand name of "Lifestyle," and you had
purchased — according to Associated Press — over one million "Life-
style" condoms were purchased by your health department. The
Food and Drug Administration then found a defective rate of ten
times higher than that set by the Food and Drug Administration;
in fact, 50 per 1,000 were found to be defective.

The FDA approved recommendation for recall of the condoms,
but no recall was ever made, nor was the Arkansas public who was
given these condoms ever informed that these were defective.

I guess my question is why didn't you feel an obligation or re-
sponsibility to warn those young girls, or boys, or whomever had
those condoms that they were carrying a loaded gun?

Dr. Elders. Senator, I think the AP may not have reported it
correctly, but it was the Arkansas Department of Health that re-
ported the defective condoms to the FDA.

Senator Coats. OK But why weren't those who had to use
them — I mean, the FDA wasn't going to use the condoms, and they
weren't at risk

Dr. Elders. And the FDA was going to force a recall, but the
company volunteered to recall the condoms and bring them back in.

Senator Coats. Did the company do that?

Dr. Elders. Yes.

Senator Coats. Was there a public campaign in Arkansas to in-
form those who had been given condoms that these were defective
and that potentially

Dr. Elders. No, sir, there was no public campaign.

Senator Coats. How were they to know, then?

Dr. ELDERS. Well, we looked at the number that was out, and we
made the decision, whether it be right or wrong, we made the deci-
sion considering the number of condoms from that group that was
out that it was in the greater public good — and sometimes, you as
a public health official have to make decisions that you consider in
the greater public good as opposed to an individual.

Senator Coats. Well, how can it be in the greater public good
when you are running a risk of 50 failures per 1,000 of not only
an unwanted pregnancy, but a lifetime sexually-transmitted dis-
ease, or even AIDS? How could that be in the greater public good?

Dr. Elders. Well, of course, you have just been fighting me
about condoms, and I have been trying to tell you that it was 50
per 1,000, but it would be 1,000 per 1,000 if they didn't use
condoms.

Senator Coats. But we are talking about a defective condom
now. We are talking about General Motors saying you keep driving

that car, and you may die in a head-on crash because your brakes
fail, and then informing the State and the State not doing anything
about it. I mean, if I were a parent

Dr. Elders. Senator, we made a public health decision. It may
have been the wrong decision, but that was the decision. After con-
ferring with the FDA, conferring with our top-level staff in Arkan-
sas, that was the public health decision that we made.

Senator Coats. Do you still believe it was the right decision?

Dr. Eldehs. Yes, I do.

Senator Coats. Even knowing that potentially some young peo-

§le using these could get AIDS, and it could be a life and death
ecisionf

Dr. Elders. Again, there were very few of those condoms, Sen-
ator, that were out, and the other thing that we — we changed; we
recalled them, we exchanged, and we got new batches of condoms
for our health departments, and we felt that really, creating a
major scare over a whole State would markedly reduce the — make
everybody afraid of the condoms and not use the condoms of the
health department. So that was the decision we made.

Senator Coats. Well, the only condoms you turned in were those
that were in the possession of the Arkansas Public Health Depart-
ment; right?

Dr. Elders. But all the condoms that were given out were in the
possession of the Arkansas Public Health Department, and where-
as they may have been out, they are out in our public health clin-
ics.

Senator Coats. Yes, but what about those that had already been
handed out to the young people?

Dr. Elders. Yes, well. Senator, those were out.

Senator Coats. In your position as Surgeon General, if a similar
situation arose, would you make the same decision?

Dr. Elders. Senator, I would pull all of the people that I felt I
needed around me to help me evaluate the decision, and I would
always try to make the decision that was what I felt was in the
best public health interest.

Senator Coats. Well, how about as a mother? What if your chil-
dren had picked up some of those condoms at school, and you later
found out that no one bothered to notify you or your child that
those condoms had a failure rate of ten times what FDA rec-
ommended? Wouldn't you be a little bit upset about that, and if
someone said, "Well, I made the decision in the best interest of Ar-
kansas public health," wouldn't you as a mother be a little upset?

Dr. Elders. Senator, the decisions I make as a mother, the deci-
sions that I make as a private citizen, and the decisions that I
make as a public health official are sometimes different.

Senator Coats. Well, in this case, don't you see some potential
tragic consequences of making a distinction between the difference
of public health director and deciding not to recall a condom that
can provide death, or unwanted pregnancy, or as a mother?

Dr. Elders. We did recall all of the — all of the condoms out of
those groups, Senator, I have told you were picked up

Senator Coats. But wouldn't you want— didn't you think that
you ought to notify people that

The Chairman. Well, Senator

Senator Coats. I mean, when you've got a potentially deadly

The Chairman. Senator, I think we are going to have to take a
break. I mean, I have listened to the answer three times. I am glad
to do whatever you want to do, but I thought you were on the

last

Senator Coats. Well, you are right. The answer is no, and I
guess I shouldn't keep pushing her.

The Chairman. If I could ask, just very briefly — and then, if
there are other questions, we'll have those — the first complaint of
condom breakage was received in the fall of 1990. The health de-
partment sent samples to the supplier for testing. The supplier in-
formed the department that the condoms met specifications, as I
understand it; is that right?

Dr. Elders. That's right.

The Chairman. The first complaint, complaint number one, your
department took action and sent it back to the manufacturer. They
said that they met the specifications.

Then, between February 1991 and June 24, the department re-
ceived four additional complaints — four

Dr. Elders. Yes, sir.

The CHAHtMAN. — about condom breakage. On July 21, the
health department stopped distribution and requested the return of
all the condoms at the public health clinics.

So you readied out to all the public health clinics and brought
those back.

Dr. Elders. Yes, sir.

The Chakman. Essentially, the department took the action on
the basis of only five complaints. Although the condoms were dis-
tributed nationwide, no other complaints were made to FDA.

Dr. Elders. That s correct.

The Chae&MAN. No other department of health in the country
made complaints, according to our records.

Dr. ELDERS. That's correct, Senator.

The Chairman. Yours did.

Dr. Elders. Yes, sir.

The Chaeiman. Now, following the action by the health depart-
ment, the department notified the FDA, and FDA tested the sam-
ples of the condoms, found them to be defective, approved a seizure
recommendation, and the seizure recommendation was voided
when the company voluntarily withdrew all the lots of the condoms
in question. Is that right?

Dr. Elders. That's correct

The Chatoman. Now, this is the second area. You were not able
to notify all of the individual clients; is that correct

Dr. Elders. That's right, Senator.

The Chakman. — because they are distributed in public health
clinics.

Dr. Elders. Yes, sir.

The Chaeiman. So you don't know all the people who have gotten
them because you don't have records of who received them all. But
you did withdraw all those that you had contact with.

Dr. Elders. Yes, sir.

The Chaeiman. So the question is did the FDA, did the Federal
Food and Drug Administration issue a public information release?

Dr. Elders. Not that I know about, Senator. We didn't receive
one.

The Chairman. The Food and Drug Administration did not. Well,
it seems to me we ought to be finding out what happened with the
FDA on this. [Applause.] Now, it is a public health issue and ques-
tion whether, after making a judgment about how many have been
distributed and what is the nature of the risk and how many are
out there, versus, as I would imagine, whether by issuing the pub-
lic information release, you are going to find that other people
might say, "Well, these other condoms might not be effective, and
therefore we won't use them," and create a public health issue. Is
that correct?

Dr. ELDERS. I think that's correct.

The Chairman. These are tough calls. There was the difference
between the killed and the live vaccines in polio. With the live vac-
cine, you immunize more children, but you are going to have a very
small but measurable percentage of those children who are going
to get polio. How do you look a parent in the eves and say, *^ell,
your child got vaccinated and got polio," and the other child who
was immunized did not get it? It is a very tough ethical, moral pub-
lic health issue and decision that you have to make, and as I un-
derstand it, you handled it exceptionally well.

I know others may be Monday morning quarterbacks and look
back on this, but I understand your answer to be that when you
have public health issues and questions like this, you want to try
to bring people together and try to make some kind of judgment
which will be in the interest of the public health. You made it with
regard to this issue; there may be others who think there should
have been a different judgment. But that is what I understand the
situation to be.

Dr. Elders. That's correct.

Senator Coats. Mr. Chairman, could I just ask on this point

The Chairman. Sure.

Senator Coats. That was a very spirited defense, which you are
very good at

The Chairman. Well, it was a factual statement.

Senator Coats. Well, Mr. Chairman, I want to challenge that be-
cause my information is that all of the defective condoms discov-
ered by FDA when they contacted Ansel were in five lots, and all
five of those lots were purchased only by the Arkansas Public
Health Department. So it wasn't a matter of contacting other
States. It was simply a matter of contacting the Arkansas Public
Health Department.

And it seems to me that whether or not the decision was made
to recall them, there was an obligation to at least issue a notice.
My goodness, if we have defective Tylenol, they put a public service
bulletin out and say don't take them— even if they don't get all of
them back from the shelves of the stores, they say, "Don't take
them. You might die." And it would seem to me that the very mini-
mal obligation ought to be at least to send word out to the 16- and
17-year-olds, who think that they've got a condom that is going to
protect them, that when you have been told that they are defective,
the least you could do is put out a notice saying there are some de-
fective condoms out there, and if you have any question, go to the

place where you got them, and well replace them. That seems to
me to be the least of the responsibilities we have with the young
people whom we give the defective condoms to.

The Chairman. I would say to the Senator there are a series of
lots. There is no indication that those are not distributed nation-
wide. Why don't we wrestle with this ourselves

Senator Coats. Yes. It is factual issue well have to determine.

The Chairman. Td be glad to, but it is my understanding that
they were distributed nationwide. And quite frankly, there is the
issue of FDA's policies with regard to this particular instance. They
talk about when they do give notification and when they don't, and
when they leave these matters up to public health considerations.
The Senator may not agree with the decision that was made on it,
but I do think that this may be a matter of sound public health.
We may have to go back and look at the actions of the Food and
Drug Administration, when they leave these kinds of issues and
questions to the public health considerations of those who are af-
fected.

The nominee made a judgment on public health grounds, and we
have a number of people — and I will put their statements in the
record — who support that public health decision, and there will be
others who may differ, but that is the situation.

I want to just touch on two final areas. Since there has been such
discussion on the condoms, I want to include in the record excerpts
from Dr. James O. Mason, who was assistant secretary for health
for President Bush. He says: "When we cannot eliminate risky ac-
tivities, we must attempt to modify and mitigate them and their
consequences. This public health role is what brought a conserv-
ative moralist, C. Everett Koop, our former SurgeonGeneral, to be-
come an outspoken advocate of condoms." Koop was Surgeon Gen-
eral during the Reagan-Bush period, and James Mason was assist-
ant secretary for health under President Bush.

Mason continues: "The tension between what some of us would
prefer that children and adults do and what they sometimes actu-
ally do is why the Public Health Service continues to urge absti-
nence in some programs and yet promotes condoms in others."

(The material referred to follows:]

Administration Support for Condom Availability

Excerpts from: Why the Government Urges Abstinence and Condoms
dr. james o. mason, assistant secretary for health

I am convinced by my experience in the Public Health Service that certain activi-
ties that I would caution young people about on moral grounds are also a clear and
serious health risk, causing, for example, about 40,000 to 80,000 deadly new infec-
tions with the AIDS virus (HIV) each year.

Of course, physicians in public health must do more than rail against such activi-
ties. When we cannot eliminate risky activities, we must attempt to modify and
mitigate them and their consequences. This 'public-health role is what brought a
conservative moralist, C. Everett Koop, our former surgeon general, to become an
outspoken advocate of condoms.

He didn't change his moral view, but his public-health view reflected a world in
which AIDS is the No. 1 disease killing American youth and a world in which many
kids are likely to experiment with their bodies and may start having intercourse be-
tween the ages of 13 and 16.

This tension between what some of us would prefer that children and adults do
and what they sometimes actually do is why the Public Health Service continues
to urge abstinence in some programs and yet promotes condoms in others.

To appropriate audiences, the need to meet health needs may also lead us to rec-
ommend to gay men certain modifications of sexual practices that, under other cir-
cumstances and with other audiences, many of us would blush to describe.

Primo Levi, the Holocaust survivor and chemist, wrote, "When we know how to
reduce the torment, but do not do it, then we become the tormentors."

We, as physicians, immunize what we can and treat the conditions we cannot pre-
vent. We moderate disorders when we can and palliate the hurt when we cannot.
But there are times when the best we can do is advise, urge and recommend — and
do it we must.

The Chairman. I will also include the statement of Antonio
Novello, the Surgeon General appointed under President Bush,
where she talks about HIV and adolescents, and urging abstinence:
"For them, we must not fail to provide adequate instruction on cor-
rect use of condoms."

And in everything I have heard from you, you have been talking
about abstinence and about the importance of values and respon-
sibility on these issues as well.

So I want to put these in as part of the record because they are
very clear indications of what the previous Surgeon General's posi-
tion has been on this issue.

[The material referred to follows :].

Excerpts from: Teen-agers' High-risk Behavior Courts AIDS

ANTONIA C. NOVELLO, SURGEON GENERAL

While ADDS experts confer in Amsterdam, the USA needs to focus on curbing the
spread of the virus among adolescents.

Studies indicate the average age of first sexual experience among U.S. adolescents
is 16. A 1990 survey of adolescents by the Centers for Disease Control reported the
54% were sexually active before finishing high school and 19% had four or more
partners.

As surgeon general, I cannot allow the spread of HIV in adolescents to continue
unchecked. We must impress upon our young people that abstinence is the only sure
way to protect themselves from acquiring a sexually transmitted disease or HTV.
But being realistic, I believe we must also educate our youth about the best ways
to protect themselves if they choose to be sexually active. For them, we must not
fail to provide adequate instruction on correct use of condoms and alert them to
their obligations and responsibilities toward their sexual partners. Above all, we
must foster in them a cautious, sensible and realistic approach to sex.

Excerpts from interview with President Bush, December 17, 1991

Q: What about condoms to teenagers?

A: "Look, it's dealer's choice. Let them try it out there. Would I want this as a
national program, something at the federal level? No."

Excerpts from Dr. James Curran, Assistant Surgeon General and Deputy

Director for HTV at the CDC

"Decisions about the role of condoms in any program for HTV and STD prevention
are best made locally, with careful attention to the context in which they are pre-
sented. We understand that the Philadelphia Board of Education decided that Phila-
delphia schools could provide condoms for students. The CDC recognizes and sup-
ports the right of each affected community to determine the course of action most
appropriate to prevent HTV infection under local circumstances."

Senator Coats. Can we keep the record open for all of us to sub-
mit like documents and questions?

The Chairman. You bet, absolutely. We will keep the record
open.

I must say that of the many things that impressed me, not only
do you know the percentage of young teenage women who are preg-

nant, but you also know the percentage of teenagers who are going
to church on Sunday. I think that is very impressive.

Senator Coats.

Senator Coats. Those are all the questions I have, Mr. Chair-
man.

The Chairman. Senator Kassebaum.

Senator Kassebaum. I have nothing further, Mr. Chairman.

The Chairman. Senator Mikulski.

Senator MlKULSKI. No questions, Mr. Chairman.

The Chairman. I will submit my additional public health ques-
tions to you. Dr. Elders.

We have had requests for other questions and answers, and we
will ask all of our colleagues to submit their questions — oh, there
is one other matter that I do want to get on the record.

I have here the financial interest statement filed in 1989. This
was the first year, as director of the Department of Public Health,
that you were under an obligation to file it.

Dr. Elders. That's right

The Chairman. That was 1989.

Dr. Elders. Yes, sir.

The Chairman. The 1990 statement cannot be located. You filed
one in 1991, and you filed one in 1992. Is that correct?

Dr. Elders. That is correct.

Senator Coats. For a minute there, Mr. Chairman, I thought you
had the missing 1989 statement. [Laughter.]

The Chairman. That would have been the end of the week that
was.

As my final statement, I just want to thank you so much for
what I think has been an extraordinary exposition on public
health, and I want to say that I have the "highest regard for your
integrity and for your commitment and have been enormously
moved by your life's experience. It will be good to have someone in
the office of Surgeon General who has the breadth of experience
and the deep, deep commitment that you have.

Dr. Elders. Thank you, Senator.

The Chairman. We will keep the record open for questions
through Monday at 6, when all the questions should be in.

Senator Kassebaum. Mr. Chairman, I would just say that be-
cause Senator Gregg is in his home State over the weekend, he
said he would have them ready for submission early next week. I
think

The Chairman. How about Monday at 6?

Senator Kassebaum. I think we'd Detter allow a couple days.

The Chairman. Well, this has been ongoing, and we want to try
to accommodate everyone. Let's have the questions in by Tuesday
noon. I think there is no reason — the Senate is in session all day
Monday, so let's have the questions in by Tuesday noon, and the
record will remain open until we have the responses to those ques-
tions.

We will consult with the members of the committee, but we are
going to schedule a time for the consideration of the nomination for
Friday, a week from today. We will be in session then.

We want to thank you very, very much.

Dr. Elders. Thank you, Senator.

85
Appendix

STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES

PART I: ALL THE INFORMATION IN THIS PART WILL BE MADE PUBLIC
Eiders Minnie Joycelyn

man tfi«n>

Position to which Oate of
nominate- Syr?*00 General nomii

nation:

Elders, Jr.

ram

tx>

n*t# of birth: August 13- l933 Place of birth; Schaal, Arkans*

***** status: M»rried Full nam* of spouse: 011ver B"

Name and ages

of children: ^ic D. Elders. 30

Kevin M. Elders. 28

Dates
Education: Institution attended

Degrees

received

Dates of
degrees

Philander Saith College 1949-1952

B.A.

May 1952

Brooke Ararjr Medical Center 1953-1956

R.P.T.

1956

OofA Medical School 1956-1960

M.D.

1960

DofMinn. 1960-1961

Ped. Intel
Ped.Resd.
M.S.

1961

OofA Medical Cencer 1961-1964

1964

OofA Medical Cencer 1965-1967

1967

(Bloc hen

Honors and awards List below ail scholarships, fellowships, honorary degrees, military medals, honorary society
memberships, and any other special recognitions for outstanding service or achievernent.

See ACCachmenC A.

Memberships: List below all memberships and offices held in professional, fraternal, business, scholarly,

civic, charitable and other organizations (or the last five years and any other prior mem-
berships or offices you consider relevant

See Attachment B. o«(c< held

Organization <if Jny) Ota

Emptoyment record: List below ail positions held since college, mduding the tine or desCTr^ion rjf j^. name of
employer, location of work, and dates of inclusive employment.
O.S. Ararjr. 1st Lieutenant. Brooke Arary Medical Center-l953-1956(M.S.(Bio<
Intern in Pediatrics. PnlvernltT nf mrm.-i.nf.. n<vt?ir<t1 Mirm,.i.r>nH«:-|<>60-
Reaidest in Pediatrics 1961

0. of AX Medical Center. Little Bock_i96i_i963

Chief Resident in Pediatrics. 0. of AS Medical Center. Little Rock-1963-

: , 1964

Research Fellow in Pediatrics. 0. of AR Medical Center, Little Rock-1964-

^_ 1967

Assistant Professor in Pediatrics, 0. of AR Medical Center. Little Rock

1967-1971

Associate Professor in Pediatrics. 0. of AR Medical Center. Little Rock

1971-1976

Professor in Pediatrics. U. of AR Medical Center. Little Rock-1976-

. , Pr*«:fnr

Director, Arkansas Department of Health. Little Rock. AR-1987-Presenc

Government
experience:

List any advisory, consultative, honorary or other part-time service or positions with Federal.
State, or local governments other than those listed above.

National Advisory- Commission on »»r»l Hf-atrh 1QQ1 - >r.»nf

Secretary's Advisory Committee for Infant Mortality 1991 - Present
Office of T-rhnr.1r.yv *««gM.nr-H>»l rh Tn«i. Ad. Cam. 1991 - Present
Human Embryology & Development Study Section-DHEU HIH 1976-1980

Murlonal »H»<corv FnnH f. Dm; r~~.< Irr^-nHTO TOA 1977-1980

Maternal & Child Health Research Committee-DHEW HIH 1981-1985

»rV»nt.t Srl>-nrr- & Tx-hnnlngv rv»— -laglnn < Srrrr rarv^ 1 97'i-1976

Governor's Commission on the Status of Woaen 1972

ArlrangKC fc^wnV T)>-v»1 np«>nr fnm1««1nr 197S-1980

North Little Rock Civil Service Coamlssion 1973-1975

Published
wntingsi

List the titles, publishers and dates of books, articles, reports or other published materials
you have written

See Attachment C.

Pgttical

WGSmbOM

and activities: List all memberships and offices held in or financial contributions and services rendered to
all political parties or election committees during the last five years.

Irma Hunter Brown Campaign for State Representative

$100 contribution. August 1990

Irma Hunter Brown Campaign for State Representative
1100 contribution, August 1992

Jay Bradford Campaign for State Senate

Future employment
reurt kinships:

J 100 contribution. April 1990

Clincon for President

$1000 contribution. August '92
Speaker at Democratic National Committee meeting

NY. NY August '92

. Indicate whether you will sever all connections with your present employer, business
firm, association or organization if you are confirmed by the Senate.

Ho. I will be on leave of absence without pay from the University
ot Arkansas School of Medicine tor two years, to be extended each

year at Che wishes of the Board of Trustees.

2. State whether you have any ptarts after completing government service to resume em-
ployment, affiliation or practice with your previous employer, business firm, associa-
tion or organization.

Yes.

3. Has a commitment been made to you for employment after you leave Federal service?
Yes, as explained above.

4. Do you intend to serve the full term for which you have been appointed or until the next
Presidential election, whichever is applicable?

Yes.

Potential conflicts

of interest 1. Describe any financial arrangements, deferred compensation agreements or other con-

tinuing: financial, business or professional dealings wilt) business associates, clients
or customers who will be affected by policies which you witt influence in the position
to which you have been nominated.

T irill by on a leave of absence trlthont pay froa the University

nf AT-fc«n<:a<: Srhool of Medicine.

2. List any investments, obligations, liabilities, or other financial relationships which con-
stitute potential conflcts of interest with the position to which you have been
nominated.

Rone.

Describe any business relationship, dealing or financial transaction wtiich you have hacj
during the last five years whether (or yourself, on behalf of a client, or acting as an
agent that constitutes a potential conflict of interest with the position to which yo-j
have been nominated.

None.

4 List any lobbying activity during the past 10 years in which you have engaged for the
purpose of directly or indirectly influencing the passage, defeat or modification of any
Federal legislation or of affecting the administration and execution of Federal law or
policy.

See llat on Page Sa.

Explain how you wil resolve any potential conflict of interest that may be disclosed by
your responses to the above items.

H/A

Junes 1988

March 1989
April 1989

August 1990
June 1991

July 1992

November 1992

Testimony on Federal Issues

U.S. Senate Committee on Health Problems of
the Lower Mississippi Delta Region

Delta Commission- chaired by Governor Clinton

Committee on Labor and Human Resources
re: Rules and regulations on abortion
clinics

Special Commission on Aging (Hash. D-C. )

Aging Subcommittee (Pine Bluff, AR)
re: Rural Health and Elderly

Senate Appropriation Committee, Subcommittee
on Labor, Health and Human Services
re: Immunizations

National Governor's Committee on Health Care

Access

re: Access for Children and Adolescents

U.S. Senate Committee on Labor and Human
Resources (written testimony submitted)
re: School Based Health Clinics

National Commission on AIDS (in capacity as
ASTHO President)

Joint Economic Commission, Subcommittee on

Education and Health

re: Social Cost of Teenage Pregnancy

-5a-

ATTACHMENT A

HONORARY DEGREES

Philander Smith College - Little Rock, AR

Doctor of Science

1989
Connecticut College

Doctor of Science

1990
Hendrix College - Conway, AR

Doctor of Laws

1990
Yale University - Connecticut

Doctor of Science

1992
Lemonye Christian College - Memphis, TN

Doctor of Science

1993
Moorehouse College of Medicine

Doctor of Science

1993
University of Minnesota

Doctor of Science

1993

HONORS AND AWARDS

Alvin C. Ehrich Award (Academy of Educational

Development:) 1993

(donated to Philander Smith College scholarship
fund)
National Coalition of 100 Black Women's Candace Award

for Health Science 1991
Chicago's De Lee Humanitarian Award 1991
American Medical Association Nathan Davis Award 1990
Southern Health Association Charles Jordan Award 1990
National Education Association Mary Futrell Award

for Creative Leadership in Women's Rights 1990
AMA National Congress on Adolescent Health Award

for Outstanding Efforts on Behalf of America's

Youth 1990
National Governor's Association Distinguished

Service Award 1989
Arkansas Democrat's Woman of the Year 1988
Worthen Bank's Arkansas Professional Women of

Distinction Award 1987
"Horizons" 100 Outstanding Women of Arkansas 1980
Distinguished Women in Arkansas 1975
Personalities of the South 1972-197 5
Alpha Omega Alpha 1972
USPHS Career Development Award 1967-1972

USPHS Postdoctoral Research Fellow 1964

B.S. Magna Cum Laude - Philander Smith College-1952

Alpha Kappa Mu National Honor Society 1951
Alumni Academic Scholarship - Philander Smith College
1949-1952 ^

ATTACHMENT B
MEMBERSHIPS

Association of State & Territorial Health Officers
(ASTHO) 1987 - present, President 1992-present

Academy of Pediatrics - Council on Government Affairs
1991 - 1992 (Advisory status at present)

Southern Regional Education Board (SREB)
1991-present

Alan Guttmacher Institute Board

1991 - present

Robert Wood Johnson Generalist Physician Initiative
Advisory Commission

1992 - present

Journal of Pediatrics (Editorial Board)

. 1991 - present
Sigma Xi President 1978-1979
Delta Sigma Theta Sorority
American Association for the Advancement of Science

1969-1977
Southern Society for Pediatric Research

President 1979-1980
Day Care & Child Development Council of America

1972
Lawson Wilkins Endocrine Society

Membership Chair 1976

Director 1985-1989
National Pituitary Agency

1977 - 1980
Human Growth Foundation

1974-1978

American Board of Pediatrics

Examiner, Endocrinology

1987-1989
Central Arkansas Academy of Pediatrics
American Diabetes Association
Academy of Pediatrics
North Little Rock Workman's Compensation Committee

1975-1979
Elizabeth Mitchell Children's Home (Board)

1971-1973
Youth Homes, Inc. (Board)

1973-1975
United Cerebral Palsy Assoc, of AR (Board)

1971-1973
Volunteers in Public Schools

1973
Northside YMCA (Board)

1973-present
Central AR National Foundation Med. Advis. Com.

1975-present

Arkansas Women's Political Caucus

1975
Arkansas Diabetes Association
National Bank of Arkansas (Board)

1978-1989
Little Rock Chamber of Commerce (Board)

1980 - present
Little Rock Rotary Club

1989-present

Paul Harris Fellow - 1991
Arkansas College Board

1992-present

ATTACHMENT C

PUBLICATIONS
1 ^M^&VsTwi' WaSUng diSCaSC »«*«*«« «** * P^aocy.

2 SSBfc&SEBg-' WT-: BioIog,cal role rf {etai *>-* hOTmone- J

3' Pref %^'57'J^' UJ" *nd McNatt' L-M" Mitochondrial manganese. Fed.

2if?J?'?-,!?dJriu^ts' EJL: R«pture of the stomach. Clinical and
experimental study. J. Lancet 86:104, 1966

S^iiJ1' **?* &*£¥** m mucopolysaccharide biosynthesis in chick
mtZ £ **??*? ""fo^ *°r Master ofScience Degree, Department of
Biochemistry University of Arkansas. 1967 ^

6. Elders. M.J., Smith. J.D.. Hughes. EH, Smith. W.G., Inhibition of

7 wr~P°T??kCCT?nde ^^F* ** a latWen. Fed. roc 26:857, 1967.
• X*7ey> J-D-. Dungan, W.T., and Elders. MJ.: Developmental interaction between

R §E |ymP><«Scui" "J cardiovascular systems. So. 6ed. J 50' W59 So7

Elders. M.J.. Parfaam, BJL. and Hughes^EJL: Prevention of wasW disease bv
pregnancy associated with hypertrophy of the fetal thymus J. Expef. bSKSms.

10- JS^3g g&f &** ^ Mangan^metabolism in the
IL 2!&l5:Si^37"SS-S-Wil*Md: ^—rticoids and muscle

12' SSSif ^W>?- Dimgan' UJ- EldeiT' and ER =■**« Third and fourth
Si^le Cirped^^?^^^ V3SCUJar "^* aDd ^TPOcaicemic

Elders. MJ., T.Garland, W.H. Daughaday, D.A. Fisher and E.R Hughes:

Regulation of growth and plasma growth hormone in Laron's dwarf, red. Res.

5:398, 1971.

Elders, ML J., H.L. Green and J.G. Jones: Hyperuricemia. Case presentation. J.

Ark. Med. Soc Dec. 1971.

Elders. M. J., J.T. Garland, W.H. Daughaday. D-A. Fisher, J.E. Whitney and E.R

Hughes: Laron's dwarfism: studies on the nature of the defect J. Ped. 83:253, 1973.

Clark. J.S., B.S. Wingfield, MX. McNatt, M.J. Elders and E.R Hughes: Studies on

the mechanism of growth retardation by glucocorticoids. Clin Res. 21:109, 1973.

Elders. M.J., B.S. Wingfield, MX. McNatt and E JEL Hughes: Somatomedin activity

in plasma of children receiving prednisone. Ped. Res. 8:324, 1973.

E.R Hughes. MX McNatt, B.S. Wingfield and M.J. Elders: Studies on the

pathogenesis of encephalomyelitis: A role for an obligatory micro nutrient? Ped.

Res. 7:192. 1973.

Elders, M J., J.T. Smith, W.G. Smith and EJL Hughes: B-anrino-proprionitrile and

mucopolysaccharide biosynthesis in the chicken Biochem. J. 136:985. 1973.

Elders. M.J.. FX. Wright. MX. McNatt. B.S. Wingfield and E.R Hughes: Brain

manganese in the developing chick. Am. J. Physiol. 227:31. 1974.

Elders. M.J.. and E.R Hughes: Heritable disorders of amy'.oid: In Kelly <ed):

Metabolic. Endocrine and ^enr<ic Digyrdcr* »f Ovid'?'? Hnrper ?nd Rowe.

Hagerstown. M.D.. 1974. vol. i. <JIu«p<. 2.

Elders. M.J. and E.R Hughes: Pyspr»teinemins and amyloidoses: disorders of

amvioid: in Tice (ed). Practice of Medicine. Harper and Rowe, Hagerstown. MD.

1974. voL 3. ChapL2.

Burnett. C.R . B. Wingfield. J. Kinney. E.R. Hughes and M.«L Elders: Alterations in

somatomedin activity and tissue lipids bv amphetamines. Cfin. Res. 22:90A. J 974

Clarke. S.. G.H. Hsynes. D.H. Berry. MX. McNatt. E.R. Hu^ies and M.J. Elders:

Mechanisms of growth retardation in childreu maintaiued on long term caucer

chemotherapy. Clin. Res. 2:90A. 1974.

McNatt. MX.. D.S. Wingfield, E.R. Hughes and M.J. Elders: Glucocorticoid

inhibition in GAGS biosynthesis: possible site of action. Ped. Res. 8:391, 1974.

Hicks, D.C.. J -A. Lee, J. Kenney, E.R Hughes and M.J. Elders: Accelerated growth

of the heart induced by glucocorticoid during embryonic development. Cliu. Res.

23:53A. 1975.

Lee. J-A. D.C. Hicks, C.R Burnett, EJL Hughes, and M.J. Elders: Stereospecific

glucocorticoid receptors in embryonic chick cartilage. Clin. Res. 23:72A, 1975.

Lee, J-A. and M. J. Elders: Characterization of cytoplasmic glucocorticoid receptors

in chick cartilage. Fed. Proc 34:352, 1975

Hicks. D.C. J.A. Lee. R Clarke, EJL Hughes and MJ. Elders: Enlargement of the

heart induced by glucocorticoids during em embryogenesis. Ped. Res. 9:277, 1975.

Frarier, EA, I.E. Glover and MJ. Elders: Adrenal insufficiency and diabetes

melHtus associated with the syndrome of inappropriate antidiuretic hormone

(SIADH) secretion. Clin. Res. 3:60A, 1975.

Fiser. RJL. P.A. Meredith and MJ. Elders: The child who fails to grow. Am.

Family Physician. 11:109, June. 1975.

Elders. WLJ., B.S. Wingfield. MX. McNatt. J.S. Clarke and EJL Hughes:

Glucocorticoid therapy in children: effect on somatomedin secretion. Am. J. Dis.

Child. 129:1393.1975.

Streeten. D.HP., F.H. Faas. M.J. Elders, and M Voorhess: Hypercortisolism in

childhood: report of two patients with stunted growth diagnosed by newer criteria.

Pediatr. 56:797, 1975.

Elders. M.J.. B.S. Wingfield. MX McNatt. J-A. Lee, and E.R Hughes:

Somatomedin and the regulation of skeletal growth. Ann Clin. Lab. So. 5:440,

1975.

Chaney, C, and M.J. Elders: Management of juvenile diabetes mellitus: J. Ark.

Med. Soc. 72:261-276, 1975

Thompson, D.. and M.J. Elders: Education of the juvenile diabetic. J. Ark. Med.

Soc. 72:239-248, 1975.

Parish, S-, and MJ. Elders: Dietary management of the child with juvenile

diabetes. J. Ark. Med. Soc. 72:192-202, 1975.

Elders, M.J., and F. Char: Possible etiology mechanisms of the Noonan syndrome.

Birth Defects. Original Article Series 12:127-133. 1976.

Skaug, W_A_, and MJ. Elders: Home management of juvenile onset diabetes

mellitus. J. Ark. Med. Soc. 72:360, 1976.

Lee. J-A., L.S. Dickinson, B.S. Kilgore. J E. Whitney and M.J. Elders: Somatomedin

activity in cystic fibrosis and reserpinized rats: possible explanation for growth

retardation. Fed. Proc. 35:262. 1976.

41. B€rry. D.H., J.A. Lee, B.S. Kilgore and M.J. Elders: Growth hormone and
somatomedin in children with acute lymphoblastic leukemia Am. Soc. of Clin.
Oncology, 1976

42. Shideler, C.E., MA Brewster. S.I. Roth. J.A Lee and M.J. Elders: Studies of bone
and cartilage growth: histochemistry, lipid metabolism correlated with age in the
developing chick embryo. Ann. Clin. LaV So G-363. 197<3.

43. McNatt. M.L.. F.M. Fiser. M.J. E'd-rs. E.S Kilcre. WO. Smith and E.R. Hughes:
Uridine diphosphate rvlosvl transfer a *~ ;»ct«f««i*s in C3r*il?ge horn manganese
deficient chicks. Biochem. J. 160:211-216. 197$.

<M. Kilgore, B., J.A. Lee, E.R. Hughes and M.J. Elders: Stimulation of xylose

incorporation into an acceptor protein by a partially purified serum factor. Clin.
Res. 25:6.

45. Reeves. R.D_. J.S. -Lee, L. Dickinson. B. Kilgore. B. Branham and M.J. Elders:
Influence of dietary protein and fat on somatomedin activity in growing rats. Clin.
Res. 25:63A, 1977.

46. Skaug. W., J. Figueroa. R Choate. R. Fiser. JA. Lee. M.D. Morris and M.J. Elders:
Glycogen storage disease type IB - possible membrane transport defect. Clin. Res
25:70A, 1977.

47. Bakdoud, Z., E. Fraser, L. Glover. W.G. Lawson. R.H. Fiser and M-J. Elders: The
association of diabetes mellitos and adrenal insufficiency in children. So. Med.
70:713-715. 1977.

48. Zonana. J.. J.F. Sotos. CA_ Romshe, DA. Fisher, M.J. Elders, and D.L. Rimoin:
Dominant inheritance of cerebral gigantism. J. Peds. 91:251-256, 1977.

49. Elders. M.J., M.L. McNatt. B.S. Kilgore and E.R. Hughes: Glucocorticoid inhibition
of glycosaminoglycan biosynthesis: decrease of protein acceptor. Biochem. Biophys.
Res. Comm. 77:557-565. 1977.

50. Lee, J A.. DC. Hicks, E.R. Hughes, D. Smith and M J. Elders: cytoplasmic
glucocorticoid receptors in embryonic chick cartilage: nature, specificity and
ontogeny. J. Steroid Biochem. 9:23-23, 1978.

51. Dickinson. W.P., D.H. Berry, L. Dickinson. H. Schedewie. R-H. Fiser and M.J.
Elders: Differential effects of cranial radiation on growth hormone response to
argining and insulin infusion. J. Pediatr. 92:754, 1978.

52. Henry. D., and M.J. Elders: Growth retardation syndromes associated with
hypophosphatemia: case reports. Ark Med. Soc J. May 1978.

53. Fiser, R.H.. and M.J. Elders: Management of children with diabetic ketoacidosis
with continuous intravenous low-dose insulin therapy. Ark. Med. Soc J. June,
1978.

54. Kobayashi, M., J.M. Olefsky. M J. Elders, et al: T^<nHn resistance due to a defect
distal to the insulin receptor (Demonstration in a patient with leprechauuism).
Proc Nat. Acad. Sci. USA 75(7)^469-3473. 1978.

55. Jacobs. RF., R.M. Nestrud, AG. Beard, R.H. Fiser. D.D. Fawcett, D.E. Hill. M.D.
Morris and M.J. Elders: An inherited syndrome of hyperglycemia,
hyperinsulinemia and failure to thrive - possible insulin defect. Clin. Res. 26l2LA,
1978.

56. Kilgore. B.S.. MJL McNatt, S. Meador. J_A Lee, EJL Hughes and M.J. Elders:
Alteration of glycosaminoglycan protein acceptor by somatomedin and inhibition by
Cortisol. Pediatr. Res. 13:96-99. 1979.

57. Marks, S.R., and M.J. Elders: The child with precocious puberty. J. Natl. Med.
Assoc. 71(2):153-159, 1979.

58. Kilgore. B., LJX Dickinson, CJEL Burnett. JA. Lee, H.K Schedewie and M.J.
Elders: Alterations in cartilage metabolism by neurostimulant drugs. J. Pediatr.
94(4):542-545, 1979.

59. Dickinson. L.C.. J-A Lee. LC. Ringdahl. H.K Schedewie. B. Kilgore and M.J.
Elders: Impaired growth in hyperkinetic children on pemoline treatment. J.
Pediatr. 94<4):533-541, 1979.

60. Stansell. P.E., M.J. Elders, KM. Fiser. J.H. Bomhofen. V. MacLeod and H.
Schedewie: Hyperglycemia secondary to diphenylhydantoin intoxication. J. Ark.
Med. Soc. 76(5):209-210, 1979.

61. Reeves. R.D.. L. Dickinson. J A.. B. Kilgore. B. Branham and M.J. Elders: Effects of
dietarv composition on somatomedin activity in growing rats. J. Nutr. 109:613-621.
1979.

62. Elders. M.J : Managing the child «.li«. i<= n <b»««i»| n<1«iH S^mal Medicine Today
Vyl. 3:?. P ?. 1979.

63. Shedewie. H.K. M.J. Elders. -J.R. Kelson. L.J Deftos. R.M. Wilkins, C. Frith and
V. McLeod: Effect of growth hormone on the control of parathyroid hormone and
calcitonin. Clin. Res. 26(6):819A, 1979

64. Herzberg, V., Boughter. M., Seyed. S.. Hill. D., Brown. R_, Schedewie H.. Elders.
M. J.: Possible etiologic mechanisms for the overgrowth and hypoglycemia in
patients with Beckwith-Wiedemann syndrome Clin. Res. 27(5):S12A. 1979

Wooten. V.. H. Schedewie. S Seyed. L. BurkJialter. J.R. Jiminez. M.J. Elders:

Autonomous interstitial cell hyperplasia causing familial precocious puberty Clin.

Res. 27(5) SOLA, 1979.

Shultz. Sam L., S. Seyed. C. Morgan, L. Burkhalter, H. Schedewie, R. Fiser, M.J.

Elders: Evaluation of the Arkansas Neonatal Hypothyroid Screening Program. J.

Ark. Med. Soc 76<7):263-268, 1979.

Schedewie. H., W. Slikker. D. Hill, R- Tsang, J. Bailey. M.J. Elders: Placental

crossover and fetal tissue distribution of l,25(OH) 2 vitamin D in Rhesus monkey.

Pediatr. Res. 14(4):930, 1980.

Herzberg. V., J.M. Boughter, SJL Carlisle. M.J. Elders, HK Schedewie. and D.E.

Hill* Relationship of erythrocyte insulin binding to abnormal growth. Pediatr.

Res. 14(4):886, 1980. m

69. Bier. D.M.. H. Schedewie. J. Lamer. J. Olefsky. A. Rubenstein. and M.J. Elders:
Accelerated fasting in leprechaunism. Pediatr. Res. 14(4):852, 1980.

70. Schedewie. H_K. E.O. Reiter, G.W. DeVane, J.F. Jiminez, IZ. Beitins, E.J. Aiman,
M.J. Elders: Primary Leydig cell hyperplasia as a possible etiology of familial
sexual precocity. Pediatr. Res. 14(4):352, 1980.

71. Lee, JAu. Dickinson, L.S. Kilgore. B.S.. Warren, R.H, and Elders, M.J.:
Somatomedin activity in cystic fibrosis and reserpinized rats: Possible explanation
for growth retardation. Ann. Clin. Lab. ScL 10(3)--227-233. 1980.

72. Bier. Dennis M., Elders, M.J.: Glucose kinetics in leprechaunism: Accelerated
fasting due to insulin resistance. J. Clin. EndocrinoL Metab. 51:988-993, 1980.

73. Herzberg, V., Boughter. M. Harris. L. Hill. D £., Schedewie. H.K., Elders, M.J.:
Erythrocyte in«aTlin receptor binding in growth hormone deficiency. Clin. Res.
28<5):S55A, December 1980.

74. Schedewie. H.K. Brewster. M.. Moriarty. M. Glover. L-. Elders. M.J.:
Trimethylaminuria: Rare or unrecognized cause of body odor? Clin. Res.
29<5>:859A, December. 1980.

75. Skaug, W.. Figueroa, J.. Choate. R., Fiser. R.. Lee. J.A-. Morris. M.D.. and Elders,
M.J.: Glycogen storage disease type D3 - possible membrane transport defect
Southern Medical Journal, Vol. 74(6):761-764, 1981.

76. Schedewie. ELK. Reiter. E.O.. Beitins. LZ., Seyed, S., Wooten, V.D.. Jiminez. J.F.,
Aiman. E. J., DeVane, G.W., Redman. J.F.. Elders, M.J.: Testicular Leydig cell
hyperplasia as a cause of familial sexual precocity. J. Clin. Endocrinol. Metab.
52:271-278. 1981.

Roth. S.I.. Schedewie, H.K. Herzberg, V.K. Elders. M.J.. Olefsky. J.. Rubenstein.
A.: Cutaneous manifestations of leprechaunism Archives of Dermatology,
117:531-535.1981.

Schedewie, Heinrich. Astrid Seifen, Joycelyn Elders, Louis Pryor, Thomas Hart,
Doyne Williams: Endocrine functions during cardiac surgery in hypothermia. Ped.
Res. 15<4):514. #446. 1981.

Stonesifer, Larry D., M. Joycelyn Elders, Victoria L Herzberg, Mark Boughter,
Thomas J. Sasasak. and Donald E. Hill: Insulin binding studies in the erythrocytes
of diabetics in one kinship. Pediatr. Res. 15<4):515, #451. 1981.
Elders. M. Joycelyn, Victoria L Herzberg, Donald E. Hill, J. Mark Boughter. Linda
Harris. Heinrich K Schedewie: Growth hormone effects on erythrocyte insulin
binding. Pediatr. Res. 15<4):507. #402, 1931.

Seyedabadi. S.. D.S. Bard. RE. Zuna. H. Schedewie. Carlos Araoz and M.J. Elders:
Epidermoid carcinoma of the vagina in a patient with cerebral gigantism. J. Ark.
Med. Soc. 73<3>:123-127. 1991.

Taylor. S.I.. Roth. J.. Blizzard. R.M.. or"! EW-rs. M.J.: Qualitative abnormalities
in insulin binding in a patient with extreme insulin resistance: Decreased
sensitivity to alterations in temperature and pH. Proc. NatL Acad. Sci. USA Vol.
73U1):7175-7176. 1981.

83. Peng. Chun Fu. Elders. M. Joycelyn. Hughes. E.R. Hicks, DC. Straub. KID..

Murphy. M.L.: Glucocorticoid effects on the embryonic chick heart: II. Alteration
of oxidative metabolism. Annals of Clin. Lab. Sci. 12<6):484-491. 1932.

34. Hicks. D.C.. Lee. J.A.. Kilgore. B.S.. Burnett. C.R, Schedewie. H.K. Hughes, E.R..
and Elders. M.J.: Glucocorticoid effects on the embryonic duck heart: I.
glucocorticoid enlargement of the heart. Annals of Clin. Lab. Sci. 12(6):479-433,
1932.

35. Elders. M. Joycelyn, H.K Schedewie, J. Olefsky. B. Givens. F. Char. DM. Bier, D.
Baldwin, RH. Fiser, S. Seyedabadi, and A Rubenstein: Endocrine metabolic
relationships in patients with leprechaunism. JNMA 74(12):1195-1210. 1982.

36. Elders, M.J., Bolze, M.S., Abdullah, S.. Schedewie. H.K, Reeves, R.D. Influence of
zinc and manganese on somatomedin and glycosaninoglycan metabolism. Clin.
Res. 30(5):886A. 1982.

37. Elders. M.J., D.E. Hill. H.K Schedewie. V.Herzberg, M. Boughter.S.I. Taylor:
Characterization of the erythrocyte insulin receptor in leprechaun ism. Clin. Res.
30(5):897A, 1982.

83. Schedewie, H., Wells. T.. Stanford, A., Elders. J.. aDd Unger, R.: Congenital

hypoglycemia secondary to persistent fetal carbohydrate metabolism. Clin. Res.
30(5) 907 A 1932.

89. Roth. Sanford L, Schedewie. H.K. Bier, Dennis M., Conaway, H.H.. Olefsky.
Jerrold. Rubensteiii, Arthur, and Elders, M.Joycelyn: Hepatic untrastructure in
leprechaunism. Virchows Arch. (PathoL Anat.). 397:121-130, 1982.

90. Taylor. Simeon I., Jose A Hedo. Lisa H. Underbill, Masato Kasuga, Elders, M
Joycelyn. and Jesse Roth: Extreme insulin resistance in association with
abnormally high binding affinity of insulin receptors from a patient with

lepr echau nism • Evidence for a defect intrinsic to the receptor. J. Clin. Endocrin.
Metab. 55(6):1108-1113, 1982.

91. Elders, M. Joycelyn: Lipodystrophies. Internal Med. 1983. Jay H. Stein, Ed. Little
& Brown Publishers pp 1985-1998.

92. Elsas, J.L., Endo. F.. Strumlauf, E., Elders, J., Priest, JJL: Leprechauhism: An
inherited defect in a high affinity insnlin receptor. Am. J. Human Genetics
(submitted 1984).

93. Fiser, Robert, Schedewie. Heinrich. Elders, Joycelyn: Disorders of Mineral
Metabolism. Practical Pediatrics, 1985.

94. Craig. J.W.. Lamer. J., Locher, E.F., Widom. B., Elders, M.J.: Mechanisms of
insulin resistance in cultured fibroblasts from a patient with leprechaunism: I.
unpaired post-binding actions of insofia and multiplication stimulating activity.
Metabolism. 33(12):1984-1095. 1984.

95. Berry. DJEL. Elders, M.J., Lui, V., Land, V., Crist W.. Sexauer. C: Growth in
children with acute lymphocytic leukemia. Med. & Ped. Oncology 11(1 ):39 1983

96. Craig. J.W., Lamer. J., Locker, E.F., Widom, B., Schedewie, HJL, Elders, M.J.:
Mechanisms of insulin resistance in cultured fibroblasts from a patient with
leprechaunism- 1, impaired post-binding actions of insulin and multiplication
stimulating activity. Abstract. Amer. Diabetes Assoc. (Diabetes 31:124A 1982.)

97. Herxberg, v.. Grigorescu. F., Elders. M.J., and Kahn. CR.: Genetic abnormality of
the insufin receptor -kinase in leprechaunism Clin. Res. 29: presented AFCR 1982.

98. Grigorescu, F.. Herzberg, V., Flier. J.S., Elders. M.J., Kahn, C.R.: Genetic defects
in the insulin receptor kinase in syndromes with severe insulin resistance. Society
of Chemical Biology. Paris. Sept.; 9-21, 1983 (presented).

99. Grigoresu. F, Herzburg. V., Flier. J.S., Elders, M.J., Kahn, C.R.: Genetic defects in
the insulin receptor kinase in syndrome with severe insufin resistance. Int. Conf.
Peptide Hormone Receptors. Regulation and Transmission of Information. 1984.

100. Fiser. R.H.. Schedewie. H.K.. Elders. M.J.: Disorders of carbohvdrate metabolism
Practical Pediatric Therapy. 1995.

101. Elders. M.J.. Schedewie. H.. F»r.e«\ F.H.: n;«:..i«|«r< «f .n-v«>„0| metabolism.
Practical Pediatric Theranv 1S«5.

102. Frindik. J.P.. Kemp. S.F., Elders. M.J.: The effect of human growth hormone
administration on the excretion of epidermal growth factor. Clin. Res. 32:8S2A,
1984.

103. Frindik, J.P., Walker, P., Zawada. M.. Kemp. S.F.. Elders. M.J.: Epidermal growth
factor binding and biological effects on gastrointestinal mucosa proliferation. Clin.
Res. 32:883A 1984.

104. Frindik, J.P., Zawada. M., Walker. P., Kemp. S.F.. Elders. M.J. : The phenotypic
expression of leprechaunism: the role of epidermal growth factor, a hormone
without a disease. Clin. Res. 32:882A, 1984.

105. Kemp. S-F.. Frindik, J.P., Ma. F.J.. Elders. MJ.: Synergistic effects of epidermal
powth factor and somatomedin in chick chondrocytes. Clin. Res. 32:895A, 1984.

106. Kemp, S.F.. Frindik, JJP-, Ma. F.J.. Elders, M.J.: Specificity of somatomedinon
cultured chick chondrocytes. Clm. Res. 32:850A, 1984.

107. Burchett, S., Maeraer. D., Steele. R_. Jacobs. R-. Elders. M.J. , Kemp. SJ.:
Immunologic profile of growth hormone deficient patients before and after growth
hormone replacement Clin. Res. 32:895A 1984.

108. Bolze. M.Sue, Reeves. Robert D., Lindbeck. Richard, Kemp, S J., Elders, M.J.:
Influence of manganese on growth, somatomedin and glycosaminoglycan
metabolism. J. Nutr. 115:352-358, 1985.

109. Kemp. S.F., Frindik, JJP-. Ma, F. J, Elders, M J.: Synergistic effects of epidermal
growth factor and somatomedin in chick chondrocytes. Pediatr. Res. 19:157A, 1985.

110. Frindik, J.P., Kemp, S.F., Elders. M.J.: Effect of growth hormone on epidermal
growth factor excretion. Pediatr. Res. 19.186A, 1985.

111. Frindik, J.P.. Walker. P., Zawada, W., Kemp, S.F., Elders, M.J.: Epidermal growth
factor binding and biological effects on gastrointestinal mucosa proliferation.
Pediatr. Res. 19:219A. 1985.

Kemp. S.F., Frindik. J.P-. Ma. F.J., Elders. M.J.: Sites of action of somatomedin on

chick chondrocytes. Pediatric Research 19:3 13A. 1985.

Frindik, JJ\, Zawada, W., Walker, P., Kemp, ST.. Byrne. W.J., Elders. MJ.: Role

of epidermal growth factor in the phenotypic expression of leprechaunisin.

Pediatric Research 19:324A, 1985.

Burchett, S.. Manner, D., Steele, R.. Jacobs. R., Elders, M.J., Kemp. S.:

Immunologic profile of growth hormone deficient patients before and after growth

hormone replacement Pediatric Research 19.182A, 1985.

Craig, James W., Lamer, Joseph, Locker, Ellen F., and Elders, M. Joycelyn:

Mechanisms of insulin resistance in cultured fibroblasts from a patient with

leprechaunism: resistance to protelytic activation of glycogen synthase by tripsin.

Molecular and Cellular Biochemistry. 66:117-125. 1985.

Elders, M Joycelyn: Lipodystrophies. Internal Medicine. Jay EL Stein, (ed).

Little & Brown Publishers, pp 1885-1839. 1985.

Elsas, L. J., Endo.F., Strumlauf, E.. Elders. M.J.. Priest J.EL: Leprechaunism: An

inherited defect in a high affinity insulin receptor. Amer. J. Human Genetics.

37:73-88. 1985.

Frindik, J. Paul, Kemp, Stephen F., Fiser. Robert H.. Schedewie. Heinrich, Elders.

M. Joycelyn: The phenotypic expression in Donohue's syndrome (Leprechaunism):

A role for epidermal growth factor (EGF). J. Peds. 107:428-430, 1985.

Griebel. May L.. Redman. John F., Kemp. Stephen F.. Elders. M. Joycelyn:

Hypertrophy of the clitoral hood as a presenting sign of neurofibromatosis in a

female child, (submitted I.

Fiser R«»K«>rt H.. Jr.. Bute*>s»n'.'i. *"Hfri«J. .<v-l«»-<|.-vo<-. H.-ini-irh. EIde«".«. M. Jovcelyn:

Thyroid Disease. Practical FyJigtrir TJAgEgRK- 21 1-- ".M«K(v

Fiser. Robert H. Jr.. Butenandt. Otfirid. Elders. M. -ku-c-lvu. Schedewie. Heinrich.

Diabetes MeUitus. Ecac.tic.al P^Lairic_Tjbex4PX 216-224.1985.

Fiser. Robert H. Elders. M.Joycelyn. Schedewie, Heinrich. vou Schnakenburg.

Klaus.: Congenital Adrenal Hyperplasia. Practical Pediatric Therapy. 233-237.

J986.

Schedewie. Heinrich, Elders. M. Joycelyn. Fiser, Robert H. Jr., Butenandt. Otfrid:

Nonendocrine Disorders of Mineral Metabolism. Practical Pediatric Therapy.

247-254, 1985.

Schedewie. Heinrich, Elders, M. Joycelyn. Fiser, Robert H.. Jr., Butenandt, Otfrid.:

Endocrine Disorders of Mineral Metabolism. Practical Pediatric Therapy. 260-262,

1985.

Schedewie, Heinrich. Elders, M. Joycelyn. Fiser. Robert H., Jr., Butenandt, Otfrid.:

Treatment of Hypercalcemia. Practical Pediatric Therapy. 260-262.1985.

Schedewie. Heinrich. Elders. M. Joycelyn. Fiser. Robert H, Jr.. Butenandt, Otfrid.:

Treatment of Hypocalcemia. Practical Pediatric Therapy, 162-263. 1985.

Kemp. ST.. Elders. M.J., Schedewie, ELK-, Vesely. D.L.: Evidence of post-receptor

defect in leprechaunism: decreased cyclic GMP levels and quanylate cyclase

activity. Clin. Res. 34:223A, 1986.

Frindik. Ji\. Morris. M.D., Kemp, S.F., Elders. M. J.: The effect of growth

hormone on lipid profiles of growth hormone deficient children. Clin. Res. 34:233 A,

1986.

Frindik. J.P.. Kemp, S.F.. Yeh. T.C.. Elders. M.J.: Possible common defect in the

pathway of polypeptide hormone action in leprechaunism Clin Res. 34:252A,

1986.

Kemp. S.F., Ma, F.J., Frindik, J.P., Elders. M.J.: Role of somatomedin in

regulation of glycosaminoglycan biosynthesis. Ped. Res. 216A: #381. 1986.

Frindik. J.P., Kemp. S.F.. Yeh, Y.C.. Elders. M.J.: Possible common defect in the

pathway of polypeptide hormone action in leprechaunism. Ped. Res. 214A#369,

1986.

Frindik. J.P., Morris. M.D., Kemp, S.F.. Elders, M.J.: Effects of growth hormone on

lipid profile of growth hormone deficient children. Ped. Res. 214A:#370, 1986.

Hu. Lei-Men, Kemp, Stephen F.. Elders, M. Joycelyn, Smith. W. Grady: Protein

phosphorylation in somatomedin-stimulated chick cartilage cells. FASEB, 1986.

Smith, W. Grady, Hu, Lei-Men. Kemp, S.F., Elders. M.J.: Evidence for

Phosphorylation of proteoglycans in chick embryo cartilage cells. FASEB. 1986.

Geflner. Mitchell E., Bersch. Noelle. Kaplan, Solomon A., Lippe. Barbara M., Van

Herle, Andre, Elders, M. Joycelyn. Golde. David W.: Growth without growth

hormone: Evidence for a potent circulating human growth factor. Lancet, Feb. 15.

343-346. 1986.

Simeon I. Taylor, Bernice Marcus-Samuels, Janice Ryan-Young. Sheryl Leventhal,

and M. Joycelyn Elders: Genetics of the insulin receptor defect in a patient with

extreme insulin resistance. J. Clin. Endocr. Metab. 62(6 ):1 130-1 135, 1986.

137. Vesely. David L., Heinrich K Schedewie, Stephen F. Kemp. J. Paul Frindik, and M.
Joycelyn Elders: Decreased cyclic guanosine 3', 5' monophosphate and quanylate
cyclase activity in leprechaunism: evidence for a post-receptor defect. Ped. Res.
20(4>:329331, 19S6.

138. Bolze. M. Sue, Robert D. Reeves, Frederick E. Lindbeck, M. Joycelvn Elders:
Influence of Vitamin A on growth Somatomedin and glycosaminoglycan
metabolism. Nutr. Res. Vol. 6:395-405, 1986.

139. Elders, M. Joycelyn, Williams, Becky, and Harris, Zenobia: Invest a Nickel, Save a
Dime - School Based Health Services for Arkansas. Journal of the Arkansas Medical
Society. Volume 85. Number 6. December. 1988.

140. Elders. M. Joycelyn: Keynote Address to the Academy for Educational
Development Conference - Urb«o M«ldle 5w-l»«w>l<= Ad«.Uc<-or.» Pr-enancv Prevention
Program. Mav 1990 AED

1J1. Elders. M. Joycelvn: Address ••• tb* JP5?«» A.u»vvi'.nn K I «•».«« ?! S«ciety Annual

Session. Journal of the Arkansas Medical Society. Vol. ?7. Num. 1. June 1990.

142. Elders. M. Jovcelyn: Address to the Robert Wood Johnson Foundation's
School- Based Adolescent Health Care Program in Princeton. NJ. ACCESS
newsletter, summer. 1990.(in progress)

143. Elders. M. Joycelyn. Hui, Jeunifer, Padilla. Steffi Essav "Adolescent Pregnancy:
Does the Nation Really Care?". Berkeley Women's Law Journal. 1989-90. Vol. 5.

144. Elders, M. Joycelyn. Hui. Jennifer: Article, "School-Based Clinics: Meeting Health
Needs of Adolescents". California Pediatrician - Spring 1990. Vol. 6.

145. Elders. M. Joycelyn, Hui, Jennifer: Paper- Adolescent Health Issues and Policy
Implications. The Southeast Regional Seminar on the Rural Family and Poverty,
Mississippi State University, February, 1990.

146. Ellis, Eileen; Kemp. Stephen; Frindik, J.; Elders, Joycelyn: Glomerulopathy in
Donohue Syndrome (Leprechaunism). Submitted to the Journal of Pediatrics -
June, 1990.

147. Elders. M. Joycelyn: Maternal and Child Health: A Challenge to our Health.
Education and Socio-Economic System. Submitted to the National AHEC Bulletin,
July 6, 1990.

148. Elders. M. Joycelyn: Promoting the Health of Adolescents. Proceedings from the
1990 State Adolescent Health Coordinator's Conference in Washington, D.C.. 1990.

149. Elders. M. Joycelyn: Adolescent Health Issues: What is Our Role? North Carolina
Medical Journal for Doctors and their Patients. May, 1991 - Volume 52, Number 5,
pp. 214.

150. Elders. M. Joycelyn: School-Based Clinics. The School Administrator. September.
1992.

151. Elders, M. Joycelyn; Hui, Jennifer. Comprehensive School Health Services: Does
It Matter and Is It Worth the Fight? Submitted to the Council of Chief State
School Officers, October, 1992.

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July 14 1993

Honorable Edward M. Kennedy
United States Senate
Washington, DC 20510-2101

Dear Senator Kennedy:

As you begin conskJentkn of the nomination of Dr. Joycelyn Elders to become
the Surgeon General of the United States, I, on behalf of 145,000 members of the
National Association of Social Workers (NASW), urge yon to support her
nomination.

Dr. Elders is one of the country^ most creditable public health officials and she
has dedicated ha life to addressing public health issues and the needs of children.

As social workers who are on the front lines of the human service delivery
system, NASW members are all too aware of the need to address the country's
human needs deficit, particularly those of children. Our members understand that
as the "doctor to the nation," the Surgeon General has a unique opportunity to
bring high visibility to such critical issues. We believe Dr. Elders is qualified and
determined to do just that.

Dr. Elders has fought for preventative health care services like childhood
immunization. t-rp^p^-^ cmldbood health screenings, and education programs for
children that focus on the dangers of drugs, HIV infection and violent behavior.
She has the courage to speak her mind based on a tremendous record of
achievement and r^"*"1 conviction. As a pro-child advocate. Dr. Elders has
staled that, "—you cant educate children if they are not healthy and you cant
keep them healthy if they are not caw iiwl — "

NASW looks forward to your leadership to insure that the Dame, weak and scope
of the debate on the nomination of Dr. Elders remains focused, as it should be,
on her prw»* integrity, her enrnprtrnrr. ucrVntiah and her pursuit of sound
public health policy.

ChEm.

jurfyCWalnJ. ACSW- 1995

ext-ojttve oatcrot

StwUo* (. GnMw ii. ACSW. usw
ASSOCIATE EXECUTIVE OCECTOtS

M»or &ooy. ACsw

IxsaBeeb*

GENEKAlCOUNSa

Cohan M C*er. JD ACSW

; ACSW. USW

Executive Director

7S0F.fj.Stw. NF_. S<«ie700. Wosh-ngion. DC 20002-4241 TB. . (2021 408-8600 TTO (202)336-8396 FAX: (2021 3368310

OOAKTMENT OF HlALTH A HUMAN lUYICU ■*• * *■

m w» ow* Dmam*
OC 3BM1

Th* honorable Senator Edward H. Kennedy

-chairman ■

Coaetittee on Labor and Hn»»n Raeourpee , ,

united IUtM fl*nat* JuL* 17' lt>93

Washington, DC 20310-Rioo

Uj. M. Joyu«lyn Kloera, K.D.

Dear Senator Kennedy:

I •■ * career ember of the 0«nlor executive service and have
been the Designated Agency Ethics Official for the Department of
Health and Human Servloe* (HIM) for th* part three yaar*. Prior
to that, X served as Deputy General Counsel at tba Department of
Energy for approximately four year* ajid eupervlaed the ethic*
Cunction in that Department ee well. Z therefore here « close
working familiarity with the practloe* of two cehlnet Deportments
with reepeot to incoming Preeidential appointee* in the neagan.
Bush and Clinton Administrations.

It ie te my knowledyw common practice throughout the Executive
Branch for incoming Preeidential appointee* to retain their
tonar positions until such time as they are oonf lraed by the
Senate.

Prior to confirmation, such nominee* say, however, legally Join
tho Oeperteent in an intermittent consultant eapaaity. ' Moreover,
from the perspective of Federal lav. there io no impediment to
tae reowipt or payments by an intermittent consultant from that
person's current non-Federal employer, for as long as that person
remains a spec la I cover naent employee (SCE) .

In the executive Branch of the United 8tatea Government, the
primary prohibition against eappleaentatlon of outside Income Is
it g.H.C. Section 209. By its terms, Section 209 "does net apply
to a special Government employee* end la thue inapplicable to all
of the many Intermittent consultants who earve the Federal
Government. (It would b»» difficult, if not Impossible, for
example, to persuade tenured members of acadealo faculties ever
to serve as intermittent consultants if such brief Federal
service required then to resign from their academic positions.)

II D.S.C. Section 202(a) defines a "special Government employes"
as an employee retained to perform "temporary duties either en a
full-time, or intermittent basis" for a period "not to exceed one
hundred end thirty days during any period of three hundred and

eixty-fiv* consecutive devs." *• Joyoelyn Cicers, M.O., began
eerviue as a consultant (SGE) to HHS en April It, 1993, on
approxismtely a two dav a week baeia until July *, 1*92, when ah*
b«g«n working for HMS on approximately a five day a week basis.
As of this dete, she hee been employed a* en SOS tor
approximately 30 workdays, veil below tbs legal limit of 13 0.

Z stand reedy to answer any further questions at any time with
respect to this matter- If X may b« of further assistance,
please do not heeitate to oontaat me at (202) 690-7219.

an identical letter hat been addressed to the Ranking Minority.

Sincerely,

Jack H. Kress

Special Counsel for Etttlee and

uesignatod Agenoy Xthloa official

tfSATQR «gss2S ""^ OT Pr<>tt offic"

iiiuuirc-iicviOT

Worthy Of Western Pennsylvania
WEDNESDAY, JULY 21 ', 7i«M

For surgeon general

The nomination of Dr. JoycelyuElden to be US. our-
geon general bo cceattrt much ado about philosophy and
ethics; UttU about quallfloulonA. Lef t look behind the
rhetoric

She is a. pre-eminent pediatrician, former moitcal
vhnni factiltyaMoiberia&tbwaxifiiorofiunneroua stud-
ies ua pediatric andoctinolofjc As head of the Arkansas
Department of Healih . she wu on able tdmlnlstra tor
who. according to Cbntf/tsriowit Quartsr(x established 2b
schuul-basefl health clinics offrrlng a ranee of services
_from hanmnhactJon to birth oantroL

And. aba is an advocate of pi wan live medidne. t
health-car* attitndw embraced by many for lis oast-cutting
jwtaurlal as weEas its sodal enlightenment
*Tet it is her ouisooxenn ess — not to mention her a rtvo-
cacy of abortion rights, sex education and distribution of
eondouia In public schools — that has put many in Con1
crass in efimk

Certainls such views desera scrutiny But wbenlast
"*re looked, tt was etfEthepraujaQro of the president —
not the Congress— tnnarainaicq.uallJ^lridtvidnilifi3r
tpp posts vrilhm the aduimlstration. IFe the durjufthe
Senate to wetgh those QjwUfiral Inns: than olthar confirm
ot reject the nomination. -

Nowhere inthe political proeats does it say (he presi-
dent must nominate on indtvidwl poll tieally acceptable
oniulpdntstoajicnugresaidrial actions. The key consid-
eration haro shonld ba qpaflflatloas And Ettea It wall
quaimed to be iht nation?! trip doctor

It's only natural that BUI Qinton would want a surgeon
ffroaral whose view* were tnJlnawim his. She would be,
in eflScx. his voice in setting the naflqtfs health policy .

True, questions has* been raised about the S&-year-old
doctor's financial dealings —bar role on an Arkansas
lank hoard, bar finally* taxes and bar continued accep-
tanoe (naffi. Sunday) of her stats salary wnl to drawing a
federal consulting fee. •

Up to now, however, the crifldsin of Dr. Elders las been
based on allegations more than facts: as such, they should
hayallttkbcaitag oaths nutsfion of ha- service asasur
geauijenerai.

In thb case, niAdical background and parfbrmance
should be the determining factors in the nomination of
DcDdensaswenoahercunflnnation. ■

■ ShelsguaMMtobemiTJ^snipmgoncralonlwa
counts. The Senate shotUd confirm her.

100

'M. Joycdyn liders, M/D.

S10 ikCarda Cove

LatkKpcfuAitsBisas 72206

July 22, 1993

The Honorable Edward M. Kennedy
Chairman

Senate Labor & Human
Resources Committee
315 Russell
United States Senate
Washington, D.C 20510

The Honorable Nancy Landon Kassebaum
Ranking Minority Member
Senate Labor & Human
Resources Committee
302 Russell
United States Senate
Washington, D. C 20510

Dear Senators Kennedy and Kassebaum:

I write in response to your request for answers to the following questions
concerning die National Bank of Arkansas.

I welcome the opportunity to address these issues in response to your
questions, and remain available to answer questions from the senators at the hearing as
welL

QUESTION 1;

Was the National Bank of Arkansas ("NBA") ever subject to a formal
enforcement action under 12 U5.C Section 1818?

ANSWER:

The NBA was subject to a formal enforcement action under 12 US.C

Section 1818 in the form of a formal written agreement between the Comptroller of the
Currency and the Board of Directors of the bank

QUESTION 2:

Did an Office of the Comptroller of the Currency ("OCC") examination
report find that any directors of the NBA engaged in practices that violated national
banking laws regarding either safety and soundness or criminal activity?

ANSWER

I was briefed at Board meetings on the contents of examination reports by
the OCC and the President of the Board. I was advised that all directors were cited in
examination reports as having violated national banking laws and safety and soundness
laws relating to their failure properly to supervise bank management I was advised
that the examination reports did not find their activity to be criminal.

101

QUESTION 3:

Did any directors of the NBA, including yourself, receive letters of
reprimand from the OCC?

ANSWER

I received a letter of reprimand solely in my capacity as a member of the
Board of Directors of NBA. I believe that other directors who served on the Board also
received letters of reprimand.

QUESTION*

Was any of your conduct cited specifically in any examination report?

ANSWER

I believe that no conduct in which I personally engaged was ever cited
specifically in any examination report.

QUESTION 5:

Were the directors ever informed by examiners that the bank management
was engaging or had engaged in unsafe and unsound banking activities or violations of
national banking laws?

ANSWER

As a result of the examination reports, Board directors were informed that
bank management had engaged in unsafe and unsound banking practices which were
in violation of national banking laws.

QUESTION fr

Did the directors take action to reasonably ensure that the activities cited
in the OCC reports would not continue?

ANSWER

I believe that although the examiners acknowledged that remedial actions
were taken, the examiners did not view those actions as sufficient to correct the

activities of bank management Thus, a letter of reprimand was issued by the OCC to
me and the other directors.

QUESTION 7:

Are you the target of further investigation?
ANSWER

I believe that I am not the target of any further investigation.
QUESTIONS:

Did the Board grant each director a $200,000 extension of credit?

102

ANSWER

The minutes of the Board of Directors meetings indicate that the directors
were given an extension of credit up to $230,000. This extension of credit was not
construed by me as 'automatic loan approval' in that each loan was subject to the usual
bank policies and procedures applied for by anyone else I abstained from the Board
vote granting me this extension of credit

QUESTION?:

If the directors received such an extension of credit, was this decision ever
cited or criticized by the banking examiners?

ANSWER

No.

QUESTION 10:

Did you ever borrow money from the NBA during the time you were a
member of the Board?

ANSWER

Yes.
QUESTION 11;

What was the purpose of (each) such loan?

ANSWER

I borrowed from the bank on various occasions under terms and
conditions available to other borrowers. The purpose of the loans was primarily for
commercial ventures, including the purchase of real estate.

QUESTION 12:

Did you ever borrow any money from the bank at preferential rates not
offered to other borrowers during the time you were a member of the Board?

103

answer-
No.
QUESTION 13;

Did you recuse yourself from discussion or approval by the Board of any
loan you had requested?

ANSWER

I recused myself from voting on the extension of credit by the other
members of the Board of Directors to myself.

QUESTION 14;

Does the Comptroller of the Currency have to approve or sign off on any
settlement agreement involving litigation alleging violations of federal banking laws?

ANSWER

Not to my knowledge.

I hope that the above responds to your questions in this area.

Very truly yours,

104

American Medical Association

Jam* * To<M. WD ;|-, \..«ri,N«.,i»^f — i|* m;i.v«»

July 9. 1993

The Honorable Edward M. Kennedy

United Suies Senate

3 IS Russell Senate Office Bui Wing

Washington. DC 20510

Dear Chairman Kennedy:

On behalf of the American Medical Association (AMA). I would like to enthusiastically
endorse the nomination of M. Joycdyn Elders. M.D. for the position of Surgeon General of
the United States Public Health Service.

The Surgeon General presently serves »n advocate for the public and an advisor to the nation
on matters of public health. In recent years, '.ne role of the Surgeon General has greatly
expanded. The Surgeon General has the opportunity to educate both the public and policy
makers on critical health issues such as AIDS, smoking, immunization, violence, nutrition.
and disease prevention.

In many ways. Dr. Elders, a pediatric endocrinologist, has trained extensively to Fill the role
of Surgeon General. As a pediatrician. Dr. Elders protected and cared for the nation" $ most
vulnerable population, its youth. In 1937. then-Governor Bill Clinton appointed Dr. Elders
to position of Director of the Arkansas Department of Health. During her tenure. Dr. Elders
worked extensively, to promote many public health issues, including greater immunization •
rates in preschool children, expanded services for.. pregnant women, increased AIDS testing
and counseling, and' improved access to heal'Ji care providers in rural and underserved areas.
In this position. Dr. Elders has provided exceptional leadership as an advocate for the health
concerns of the public

For her contributions to public health. Dr Elders has earned numerous awards, including the
AMA's 1990 Nathan Davis Award and me aMA's 1990 National Congress on Adolescent
Health Award for Outstanding Efforts on Behalf of America's Youth. She currently serves .
as President for the Association of Stzie and Territorial Health Officers. Dr. Elders is a
graduate of Philander Smith College in LitUe Rock and the University of Arkansas Medical
School.

Dr. Elders brings the requisite experience, know-ledge and commitment to provide leadership
as Surgeon General. The nation would be well served by her appointment to this critio:
position in the Clinton Administration. Tfce AMA appreciates the opportunity to convex- .iur
full support for Dr. Elders and to urge you co confirm her to the position of Sureeon
General. We look forward to working wish Dr. Elders in the future.

Sincerely.
JamL's. Todd. MD

105

NATIONAL ENDORSEMENTS FOR DR. ELDERS
as of 27 July 1993 (12.00 pm)

9 to 5

A. Phillip Randolph Institute

ActionAIDS

Adolescent AIDS Program

AIDS Action Council

AIDS National Interfaith Network

Alan Guttmacher Institute

Alliance for Young Families

Alliance to End Chiklhood Lead Poisoning

Alpha Phi Alpha Fraternity. Inc.

Ambulatory Pediatric Association

Ambulatory Pediatrics Association

American Academy of Child and Adolescent Psychiatry

American Academy of FamBy Physicians

American Academy of Pediatrics

American Association for World Health

American Association of Black Cardiologists

American Association of Dental Schools

American Association of Medial Schools

American Association of School Administrators

American Association of Sex Educators. Counselors, and Therapists

American Association of University Women

American Cancer Society

American Civil Liberties Union

American College Health Association

American College of Obstetricians and Gynecologists

American College of Physicians

American College of Preventive Medicine

American Cyanamid Company (Lederie Laboratories)

American Dietetic Association

American Federation of Labor-Congress ot Industrial Organizations

American Federation of Teachers

American Federaton of State and County Municipal Employees. AFLCIO

American Fertility Society

American Foundation for AIDS Research

American Friends Service Committee

American Heart Association

American Home Economics Association

American Jewish Congress

American Library Association

American Lung Association

American Medical Association

American Medical Student's Association

American Medical Women's Association. Inc.

American Nurses Association

American Occupational Therapy Association, Inc.

American Orthopsychiatric Association

American Pediatric Society

American Psychiatric Association

American Psychiatric Society

American Psychological Association

American Public Hearth Association

American School Food Service Association

American School Health Association

American Schools of Public Health

American Social Hearth Association

American Society for Adolescent Psychiatry

American Society for Clinical Nutrition

American Society for Medical Technology

American Society for Parenteral and Enteral Nutrition

106

American Society of Pubfic Health

Americans for Democratic Action, Inc.

Artemis Project

Asian American Hearth Forum, Inc.

Asian/Pacific AIDS Coalition

Asians and Pacific Islanders for Reproductive Health

Association for the Advancement of Health Education

Association for Vital Records and Health Statistics

Association of American Medical Colleges

Association of Asian/Pacific Community Health Organizations

Association of Black Cardiologists. Inc.

Association of Black Sociologists

Association of Faculties of Graduate Prograns in Public Health Nutrition

Association of Junior Leagues International

Association of Local Health Liaison Officials

Association of Maternal and Child Health Directors

Association of Maternal and Child Health Programs

Association of Reproductive Hearth Professionals

Association of Schools of Public Health

Association of State/Territorial Chronic Disease Program Directors

Association of State/Territorial Dental Directors

Association of State/Territorial Directors of Nursing

Association of State/Territorial Directors of Pubfic Health Educators

Association of State/Territorial Health Officials

Association of State/Territorial Local Health Liaison Officials

Association of State/Territorial Public Health Education

Association of State/Territorial Public Health Laboratory Directors

Association of State/Territorial Public Health Nutrition Directors

Association of State/Territorial Public Health Social Work

Association of the Faculties of Graduate Programs in Pubfic Health Nutrition

Association of Women's Health, Obstetric, and Neonatal Nurses

Assoicated Group

B*Nai B'rith Women

B'nai B'rith

Biotechnology Industry Organization

Black Leadership Forum

Black Women's Agenda, Inc.

Business and Professional Women/USA

Campaign for Fairness

Campaign for Women's Health

Catholics for Free Choice

Catholics Speak Out

Center for Population Options

Center for Reproductive Law and Policy

Center for Science in the Pubfic Interest

Center for Women Poficy Studies

Child Welfare League of America

Children and Youth 2000

Church Association for Community Services

Church Women United

Citizen Action

Clinical Directors Network Region II, Inc.

Coalition for Nutrition Services in Health Care Reform

Coalition for School-Based Primary Care

Coalition of 100 Black Women

Coalition of Black Trade Unionists

Consumer Federation of America

Coalition of Labor Union Women

Coalition on Smoking OR Health

Commission on Pan-Methodist Cooperation

Commissioned Officers Association of U.S. Public Health Service

Committee for Education Funding

Congressional Black Caucus

107

Congressional Caucus for Women's Issues

Consumer Federal of America

Consumer Federation of America

Council for State and Territorial Epidemiologists

Council of Chief State School Officers

Council of Great City Schools

Council of State/Territorial Epidemiologists

Council of the Great City Schools

Delta Sigma Theta Sorority. Inc.

Doctors Ought to Care

Drug. Hospital, and Health Care Employees Union

Education/Training/Research Associates

Environmental Defense Fund

Family Planning Center. Inc.

Food Research and Action Center

Fund for the Feminist Majority

Funders Concerned about AIDS

Girls, Inc.

Harvard School of Public Health

Health Policy Institute

Hetrick-Martin Institute for Gay and Lesbian Youth

Hispanic Nurses Association

Human Rights Campaign Fund

ILGWU

Institution for Advanced Study of Human Sexuality Alumni Association

International Coal'rton of Women Physicians. Inc.

Japanese American Citizens League

Juvenile Diabetes Foundation International

Kappa Alpha Psi Fraternity. Inc.

Large Council Executive Director's Association

Legal Defense and Education Fund

March of Dimes. Birth Defects Foundation

Martin Luther King Center for Nonviolent Social Change

Maternal & Child Health Institute

Maternal and Child Health Institute (Atlanta)

Mexican American Women's National Association

Minority Cardiovascular Disease Prevention Task Force

Ms. Foundation for Women

NAACP

NAACP (Little Rock)

NAACP Legal Defense Fund

National Abortion Federation

National Abortion Rights Action League

National Alliance of State and Territorial AIDS Directors

National Assembly of State Arts Agencies

National Assodarton of Secondary School Principals

National Association for Equal Opportunity in Higher Education

National Association for Sickle Cell Disease

National Association of Black Psychologists

National Association of Children's Hospitals and Related Institutions. Inc.

National Association of Community Hearth Centers

National Association of County Health Officials

National Association of Ecumenical Staff

National Association of Elementary School Principals

National Association of Health Services Executives

National Association of Labor Workers

National Association of Pediatric Nurses and Practitioners

National Association of People with AIDS

National Association of Protection and Advocacy Systems

National Association of School Nurses

National Association of Secondary School Principals

National Association of Social Workers

National Association of State Alcohol and Drug Abuse Directors. Inc.

National Association of State Boards of Education

108

National Association of WIC Directors

National Black Caucus of State Legislators

National Black Child Development Institute

National Black Nurses Association (40 letters)

National Black Women's Health Project

National Catholic AIDS Network

National Caucus and Center on Black Aged. Inc.

National Coalition to Support Sexuality Education

National Committee on Pay Equity

National Community AIDS Partnership

National Consumers League

National Council of Jewish Women

National Council of Negro Women

National Council of Senior Citizens

National Council on Alcoholism and Drug Dependence. Inc.

National Council on Family Relations

National Education Association

National Education Association Health information Network

National Environmental Health Association

National Episcopal AIDS Coalition

National Family Planning and Reproductive Health Association

National Federation of Business and Professional Women's Clubs, Inc.

National Foundation for Infectious Diseases

National Gay and Lesbian Task Force

National Jewish Democratic Council

National Lawyers Guild

National Leadership Coalition on AIDS

National Lesbian and Gay Health Foundation

National Medical Association

National Medical Political Action Committee

National Minority AIDS Council

National Multiple Sclerosis Association

National Native American AIDS Prevention Center

National Network of Runaway and Youth Services

National Network of Runaway Services

National Organization of Women (NOW)

National Organization of Women Legal Defense and Education Fund

National Organization on Adolescent Pregnancy, Parenting, and Prevention

National Organization Responding to AIDS

National Pan Hellenic Council

National Pediatric HIV Resource Center

National Poetical Congress of Black Women

National Program to Prevent Unintended Pregnancy

National PTA

National Public Health Information Coalition

National Puerto Rican Coalition, Inc.

National Resources Defense Council

National Rural Health Association

National School Boards Association

National Smoking Cessation Center for African American Women

National Task Force on AIDS Prevention

National Urban Coalition

National Urban League

National WIC (Women's Infants, and Children) Directors

National Women's Law Center

109

National Women's Political Caucus

Northwest AIDS Foundation

Nutrition Coalition for Health Care Reform

Older Women's League

Omega Psi Phi Fraternity. Inc.

Operation PUSH

Organizadon Naaonal de La Salud de La Mujer Latina

Partnership for Prevention

Pediatric AIDS Foundation

Pension Rights Center

People for the American Way

Phi Beta Sigma Fraternity

Philadelphia AIDS Coalition

Physicians for Social Responsibility

Planned Parenthood Federation of America

Presbyterian Church USA

Produce for Better Hearth Foundation

Produce Marketing Association

Public Citizen

Public Hearth Foundation

Public Hearth Information Services

Public Voice for Food Policy and Health

Religious Action Center of Reform Judaism

Sara Lee Corporation

Sex Information and Education Council of the U.S.

Sigma Gamma Rho Sorority, Inc.

Society for Adolescent Medicine

Society for Nutrition Education

Society for Pediatric Research

Southern Christian Leadership Conference

Southern Regional Project of Infant Mortality

State Family Planning Administrators

Therapeutic Communities of America

Tobacco Free Heartland

U.S. Conference of Local Health Officials

U.S. Conference of Mayors

UAW

Union of American Hebrew Congregation

Unitarian Universalis! Association of Congregations

United Church of Christ Office for Church in Society

United Food and Commercial Workers International Union. AFL-CIO and CLC

United Methodist Church and Society

United Methodist Women

Voters for Choice

Wider Opportunities for Women, inc. (WOW)

Woman Activist Fund

Women and Poverty Project

Women's International League for Peace and Freedom

Women's Legal Defense Fund

World Federation of Hemophilia

YWCA of U.S.A.

Zero Population Growth

STATEXLOCAL ENDORSEMENTS

100 Black Women of Long island. Inc.

Adolescent AIDS Program of the Montefiore Medical Center

AIDS Project Los Angeles

AIDS Service of Dallas

Alabama State Nurses Association

Alaskans/Americans Living with HIV

Alliance for Young Families

American Association of University Women of Maine

110

American Lung Association of Illinois
Arkansas Advocates for Children and Families
Arkansas Baptist College

Arkansas Chapter of the Society for Public Health Education
Arkansas Children's Hospital
Arkansas Department of Health
Arkansas Hospital Association
Arkansas Medical Dental Pharmaceutical Association
Arkansas Medical Society
Arkansas Minority AIDS Task Force
Arkansas Minority Health Commission
Arkansas PTA

Arkansas Public Health Association
Arkansas State Board of Health
Atlanta Neighborhood Development Partnership. Inc.
Black Nurses' Association
Boston Women's Health Book Collective
Broadway Cares/Equity Fights AIDS
Brooklyn Pediatric AIDS Network
California Teen Pregnancy and Parenting Coalition
Care Planned Parenthood of New York City
Central State University of Ohio
Chicago Area Immunization Campaign
Chicago Public School System
Chicago Women's AIDS Projects
Chicano/Latino Medical Association of California

Children's Center
Children's Diagnostic and Treatment Center of South Florida
Children's Hospital of Columbus, Ohio
City of Los Angeles AIDS Coordinator
Coalition for School-Based Primary Care
Coalition of 100 Black Women (of metropolitan Atlanta)
Coalition of Black Trade Unionists
Colorado Academy of Family Physicians. Inc.
Community Health and Education Program of the Columbia University School of

Community Hearth Connection of Wilkes. Inc.; NC

Community United Methodist Church

Community United Methodist Church of Brighton. MA

Council of Black Nurses of Los Angeles

Education/T raining/Research

El Centra del Pueblo of Los Angeles

Englewood Health Department of New Jersey

Family Planning Center. Inc.

Family Hearth Council of Central Pennsylvania

Family Health Council of Pennsylvania

Family Planning Advocates of New York State. Inc.

FamBy Planning Association of Maine

Family Planning Center. Inc.

Family Planning Council of Cayuga County

Family Planning Council of Iowa

Family Planning Council of New Hampshire

Family Planning Council of Southeastern Pennsylvania

Feminist Women's Health Center of Atlanta

Green Hills Community Action Agency

Harbor Sweets

Health First

Hollywood Women's Political Committee

Horta Pharm B.V. of the Netherlands

Idaho Women's Network

Illinois Maternal and Child Health Coalition

Johns Hopkins University School of Medicine - Department of Pediatrics and the

Kalamazoo AIDS Resource and Education Services

Kansas Department of Health and Environment

Kansas Health and Environment Chronic Disease Control Division

Ill

Legal Action Center

Life Foundation

Lincoln County Nursing Service

Little Rock Black Nurses' Association

Los Angeles Immunization Coalition

Los Angeles Regional Family Planning Council. Inc.

Louisiana Department of Hearth and Hospitals

Louisiana Office of Public Health

Magic Valley Citizens for Choice

Maine Chapter of NOW

Maine Choice Coalition

Maine Civil Liberties Union

Maine Women's Lobby

Massachusetts Committee for Children and Youth

Massachusetts Nurses Association

Massachusetts Nutrition Board

Massachusetts Public Health Association

Maternal and Child Health Coalition of Nevada

MeckJenberg Council on Adolescent Pregnancy

Medico-Chirurgical Society

Memphis and Shelby County Health Department

Mercy Family Medicine Residency Program; Denver. CO

Mercy Medical Center

Metropolitan Washington Public Health Associaiton

Minority Task Force on AIDS

Mississippi Conference on Social Welfare

Mississippi Health Advocacy Program

Mississippi State Department of Health

Missouri Health Council. Inc.

Municipality of Anchorage Department of Health and Human Services

NAACP (Little Rock)

National Association of Children's Hospitals and Related Institutions. Inc.

National Association of Fashion and Accessory Designers Inc

National Association of Negro Business and Professional Women's Clubs. Inc.

National Coalition of 100 Black Women. Inc. of Virginia

New Hampshire Family Planning Council

New Jersey State School Nurses Association

New Mexico Community Foundation

New Mexico Department of Health

New York City Commission on the Status of Women

New York State Department of Health AIDS Institute

North Carol na Coalition on Adolescent Pregnancy

North Dakota Department of Health. Division of Health, Promotion and Education

North Dakota State Department of Health and Consolidated Laboratories

North Jersey Medical Society

NOW-San Francisco Chapter

Ogala Sioux Tribe

Oklahoma Sooner City Alumnae Chapter

Oregon Department of Human Resources Health Division

Pediatric AIDS Demonstration Project for Alabama

People with AIDS Coalition of Tucson

Philadelphia AIDS Coaltion

Philander Smith College

Physicians Association of Louisiana. Inc.

Planned Parenthood of Alaska

Planned Parenthood of Broward County, FL

Planned Parenthood of Buffalo and Erie County

Planned Parenthood of Chester County of Pennsylvania

Planned Parenthood of Delaware and Otsego Counties

Planned Parenthood of East Central Illinois

Planned Parenthood of Essex County

Planned Parenthood of Greater Iowa

Planned Parenthood of Greater Kansas City

112

Planned Parenthood of Greater Northern New Jersey
Planned Parenthood of Greater Western Michigan
Planned Parenthood of Lincoln
Planned Parenthood of Memphis
Planned Parenthood of Monmouth County
Planned Parenthood of New York City

Planned Parenthood of Niagara County

Planned Parenthood of Northern New England

Planned Parenthood of Northern New York

Planned Parenthood of Rochester and Genesee Valley, Inc.

Planned Parenthood of San Mateo County; CA

Planned Parenthood of Southern Tier. Inc.

Planned Parenthood of Suffolk County

Planned Parenthood of Summit Portage and Medina Counties

Planned Parenthood of Tompkins County

Planned Parenthood of West Michigan

Planned Parenthood of Wisconsin

Pro-Choice Coalition of West Tennessee

PROTOTYPES

Public Health
PWA (People with AIDS) of Jacksonville. FL
Retired Senior Volunteer Program
Sage United Methodist Church of Monterey Park, CA
Shelby County Adolescent Pregnancy Prevention Council of Tennessee
Southwestern Jefferson County Consolidated School Corporation of Indiana
State of Alabama Department of Health
State of Tennessee Department of Education
State of Tennessee Department of Health
Surry County Department of Health
Texas Family Planning Association
United Brotherhood of Carpenters and Joiners of America
United Methodist Church of Harrisburg
United Methodist Church of Little Rock
United Methodist Church of Pine Bluff
Upper Hudson Planned Parenthood
Utah Public Health Association

Violet-Cherry-Englewood Health Department, New Jersey
Waianae Coast Comprehensive Health Center
Washington State Department of Health
Washington Urban League
Women's Bar Association of Washington, D.C.
Women's International League for Peace and Freedom

PERSONAL ENDORSEMENTS

Jo Ann Spees
Lilla Natson

Patricia A. Nolan Executive Director of Colorado Department of Health

Enid Hickman

Anne Hess

Diane Murray

Sukey Wagner Iris House

Suki Terada Ports

Sheila G. Holden

MaJinda Miles

113

Peter D. Relyea

Deborah C. Francis

Linda Haynie Green

Audrey Opulski

Mary Ellen Yamashita

Dorothy Johnson

Lome Luahnat Bellair

Tonya Hall

Catherine Saalfield

Beverly Ratter

Petra Allende

Linda Gang

Bambi T. Magie

Mary K. Richards and colleagues

Peggy L Kopf

Myrta Cuadro

Liat E. Applenhite

Deruce Williams Johnson

Wei Lam

Dave Cutler

Yvette Green

Debbie Dotson

Mary N.D. Matanane

Agnes Molnar

Cynthia A. McKinney

Electra Kimble Price

Valyrie K. Laedlein

Jeannette Bobst

Terry M. Stone

Ann Jueschke

Rev. Richard A.Schlosser

Diana Slutzman

Cartton Newsome

Ann Whitehead

Gwen E. Bowman

Diane Kujawa

Hilary House

Leslie J. Bille

Carol A. Perhach

Joan Fields

James FL Miller

LaShime McBride

Debra Cooper

Anthony Houston

Grace E. Groves

O'Neill Blacker-Hanson

Martha Parry

Susan Edwards

Bonnie L SoBoway

Dr. and Mrs. Charles P. Hadley

Henry A. Waxman

Irwin Redener

Roosevelt Brown

Isadore Seeman

Karen Heck

Hannah Sktofsky

Lois Moore

Sandi von Scoyoc

Margaret V. Todd

John H. Stoner

Nicole Simpson

Douglas S. Lloyd

J. Smith

Ingrid Scott Weekley

Pima County Health Department

Sullivan County Regional Health Department
Maternal Child Health Program of Guam

United States Representative

Lane County Public Health Services Manager

Josephine County, Oregon Health Department
Sullivan County Regional Health Department

Detroit Department of Hearth
Onondaga County Health Department

WTLV-12

U.S. Representative

Kennebec Valley Community Action Program

Delta Sigma Theta
Charlotte-Mecklenburg Schools

114

Jane Kravotil
Mary E. Henry
F. Herbert Skeete
Mariilyn W. Derig
Julia Minoia
Barbara Floyd
Rims Barber
Patricia 0. Mail
Willie E. Francis
David L White
Dianne E. Christensen
Michael H. Rhodes
Maureen Homenick
John F.Higdon
Paul and Janet Haynes
Gail G. Church
Carolyn H. Stewart
Patricia Barber
James H. Uttred
Michael Burkhart
Ronald Levine
Michael Skeels
Peter Somani
Ed Thompson
Coleen Kivlahan
Christopher Atchison
Dr. and Mrs. Glenn White
Margaret Dionne
S. P. Meyn
Marie C. Meglen

Laveme Ah/es Snow

Jeanece Seals: Margaret Major

Johana Wiese

Sadako S. Holmes

John Lumpkin

Sidney Alexander

Jack Dillenberg

Mimi Fields

James Lieberman

Faye Wilson

T.W. Lewis. Ill

Patricia Nolan

Agnes Dolores Lattimer

Elizabeth Karlin

Laura M. Keefe

Rice Leach

Larry Hebert

Lani Graham

Nelson Sabatini

David Mullligan

Gregg Wright

Allan Noonan

RodBetit

Jan Carney

Robert Stroube

Jane Sabes

Cindy Howard

Sheila J. Webb

Rosemary M. Jones

Ray Baker

Armando I. Smith

Harvey V. Fineberg

Millicent Y. Cox

United Methodist Church of Boston

Jacobus Center for Reproductive Hearth
Curry County Health Department
Mississippi Human Services Agenda

Brunswick County Health Department
The Momentum Project

National Political Congress of Black Women

Philadelphia AIDS Consortium
New Mexico State Health Official
North Carolina State Hearth Official
Oregon State Health Official
Ohio State Health Official
Mississippi State Health Official
Missouri State Health Official
Iowa State Health Official

South Carolina Department of Health and

Environmental Control

Utah Public Health Association

State of Tennessee Department of Health

Illinois State Health Official

Lahey Clinic of Burlington, MA

Arizona State Health Official

Washington State Health Official

Director of Hearth; Greenwich. CT

General Board of Global Ministries

Miltsaps College

Colorado State Health Official

Medical Director of Cook County Hospital

Women's Medkal Center of Madison

Kentucky State Health Official
Louisiana State Health Official
Maine State Health Official
Maryland State Health Official
Massachusetts State Health Official
Nebraska Passt State Health Official
Pennsylvania State Health Official
Utah State Hearth Official
Vermonst State Health Official
Virginia State Health Official
Wyoming State Health Official

Department of Health of New Orleans
Tioga Opportunities Program. Inc.
Kansas State Health Official

Harvard School of Public Healtlh
United Methodist Church

115

Erima J. Vaughan\
Consuelo Saragoza
Charles F. Fiagg
Stella Reinstein
Ann C. Hobson
Christine A. Forester
Mary Ann Oakley
Louisa Woodward
Cindy Goldstein
Jane H. Lee
Mary Parker
Johanna Dwyer
Peter D. Wilson
Robert C. Harder
Joan K. Leavitt. M.D.
Jean G. Brown
Sima D. Michaels
Linda Polk

Robert W. Johnson. Jr.
Tom Dressier
Anna Dillman
Susan S. Addtss

Paul W. Nannis
Barbara D. Martin
Lynn Cooper Breckenmaker
David R. Smith
Elena Rios
Beth E. Dozoretz
Alan Blum
Robert C. Harder
Harold Wimmer
Marion A. Humphrey
Penni Eldredge-Martin
Wella Washington
John Lewin
Ron J. Anderson
Robert Cunningham
Jeanne Kiefner
Margaret and Peter Strumpf
Kimberty D. Jones
Tom Brown
Joan Campbell
Barbara Debuono
Larry Herbert
Dr. C Everett Koop
Paul Nannis
Samuel Rogers
Alex Vinson
Bernard Barth
Tonie Fleming
Samuel H. Thomas.lll
Nicheile Schoultz
Damon Green
Sharon McGIII
Kim Williams
Frances Grace Block
Mark and Claudia Washburn
Sheila MaJoney
Arthur and Anne Johnson
Hermann Mendez
Virginia Benker-Beck
Christina Lightbourne
Martha C.

New England Medical Center

National Association of Children's Hospitals

Department of Health and Environment of

Former Health Official of Oklahoma; Past

Family Guidance Center (Missouri)

Los Angeles Regional Family Planning Council

Commissioner of Connecticut Department of
Public Health and Addiction Services
Commissioner of Health of Milwaukee

Family Health Council of Central Pennsylvania

Texas Department of Health

The Chicano/Latino Medical Association of

First Hospital Corporation (Virginia)

Baylor College of Medicine/Doctors Ought To

Kansas Department of Health and Environment

American Lung Association of Illinois

Circuit Judge of Little Rock

Alpha Kappa Alpha

Hawaii State Health Official

Parkland Memorial Hospital; Texas Board of Health

NASN Director of New Jersey

State Health Official of South Carolina
General Secretary, National Council of Churches
State Health Official of Rhode Island
State Health Official of Louisiana

Milwaukee Department of Public Health
Community Health Center. Kansas City . MO

Children's Medical Center of Brooklyn
Erie Medical Center

116

Tracee N. Murphey

Dr. E.B. Johnson, Jr.

Julie L Webster

Pat Donze Shae

Jonathon Makepeace

Pamela T. Wright

BethTeubert

Ian Thompson

Lynne Mohe

Dorothy Morris

Kara C. Mariaca

Mr. and Mrs. Robert W. Schafer

Mildred S. Morse

Mr. and Mrs. Simon L Cohen

Deanna Durica

Mark B. Horton

Donald Kwafick

Bruce Siegel

Mr. and Mrs. Foster Brandt

Robert W. Dunn

Vivian O. Lee

Lee R. Heck

Lawton Chiles

James D. Thomas

LessieF. Laris

Summiya Wimbish

Elica Ware

Sandra Soute

Carolyn Barge

Ah/irita W. Little

Christeen Johnson

Margaret C. Ledbetter

Jim Ledbetter

Donna M. Green

Sheila Newbery

Silvio Levy

Janice Wfils

Cynthia Barnes

Claudia L Webster

Sara E Ort

RrtaGuiton

Barbara S. Cambridge

Kevin E. Vaughan

Ramon Martin Garcia

Health Council

Chris R. Harvey

Barbara Taylor

Jacqueline Joy Guines

Carol Elliott

Denysse C. Brown

Hannah T. Lusk

David Ehrenstein

Leanne G. Porterfield

Morse Enterprises, Inc.

Yukon-Kuskokwim Health Corporation
Director of Department of Health of Nebraska
Nevada Stale Health Official
New Jersey State Health Official

Director of Revenue Development of Dallas
Governor of Florida

Georgia Director of the Department of Health
National Medical Association. Region 1

City of Philadelphia on Commision on Human
Northeastern Sonora-Cochise County Bi-National

Lancaster AIDS Project

117

Frances Evans
Janice Risser
Catherine H. Goulet
Ernest J. Moch
Likithia Sanford
Beth and Joseph Simon
Jack Hataway
John FL Bagby
Verena Wheeler
Anne Honford Olson
Kay F. Lanier
Samuel B. Teague
JerakJL Scott

EUen Kirby
Barbara Tausey
Cynthia B. Camese
Barbara Thompson
Stephanie Anna Hixon
Cecelia M. Long
Myra J. Christopher
Yvonne Stone Hurton
Diane Brown
Thomas Thompson
Cindy Willson
Thomas D. Peace
of Health

Donald Williamson
Dolly W. Adams
Stanley K. Tupper
Steve Palumbo
Susan M. Horbaday
Charles S. Mahan
Annette Long
Kerry Kirschner
Bradford Wyche
Sarah Ochs
Heather L Hoesel
Carol Ann Mallory
Marilyn S. Adams

Sharon L McAllister
Ann Hafer
D. FL Bethune
Eugene J. Jordan
Paul W. Nannis
Robert Miller
MatfJe FL Crossley

Lakeside United Methodist Church

National Director of the Special Program on

The United Methodist Church

Alpha Kappa Allpha Sorority. Inc.
General Commission on Religion and Race.
The General Commission on the Status and
Role of Women; the United Methodist Church
Mkjwest Bioethics Center

Commissioner of the Oklahoma State Department

Alabama State Health Official
Black Women's Agenda. Inc.
Former U.S. Representative

State Health Officer of Florida

Director of Development; Mote Marine Laboratory

Katz-Mallory. P.C.

President. Board of Directors Planned

Parenthood of Memphis

American Cyanamid Company
President of National Dental Association
Health Commissioner of City of Milwaukee
Member. Arkansas State Board of Health

118

Sharon D. Tucker

F. Anthony Bell

Joe L Hargrove
Gerakfine K. Rayford
Phillnp L Rayford
Ann Dixon
Carole K. Bebelle
Betty Anderson
Lynda K. Anderson
A. Henry Thomas
Richard B. Wilke
Kathryn S. Taylor
Bill Wilson
Maroa Gfario
Gertrude McWilliams
Becky and Ken Stenton
Mila Castro Morelos
Metvin G. Talbert
Mrs. Elin Greenberg
Georges C. Benjamin

Municipality of Anchorage Department of Health and

Human Services

Municipality of Anchorage Department of Health and

Human Services

Cardiology and Medicine Clinic. P.A.

University of Arkansas for Medical Services

National Association for Sickle Cell Disease, Inc.
Bishop of United Methodist Church

United Methodist Church of Methodist
Susan G. Komen Breast Cancer Foundation

119
American College of Physicians \ ' " ' ♦-•««

July 12, 1993

The Honorable Edward M. Kennedy
U.S. Senate
Washington, DC 20510

Dear Senator Kennedy:

The American JSbUegc Of Physicians, representing more than 80,000 physicians
practicing internal medicine and 'its subspecialties, strongly supports the confirmation of
M. Joycelvfi Elders, lAD^af'u.S. Surgeon General.

Dr. EMfcrs b>><yro-certified pediatric endocrinologist, holds a Master of Science
degree in^^henustry, and is author of more than 150 scientific articles for medical
publications. Prior to becoming Arkansas Director of Public Health in 1 987, she served
as President of the Association of State and Territorial Health Officers, and has served
on numerous distinguished panels, such as the National Advisory Committee on Rural
Health. She is the recipient of more than a dozen awards for her achievements,
including the AMA National Congress on Adolescent Health Award, the National
Eduction Association's Award for Creative T radcrship in Women's Rights, and the
National Governor's Association Distinguished Service Award.

As Director of the Arkansas Department of Health since 1987, Dr. Elders tackled
difficult public health challenges and amassed a record of achievement through innovative
approaches to difficult problems. She initiated a plan to expand home health care in
Arkansas allowing senior citizens or medically fragile patients to remain in their
communities. In 1990, Dr. Elders instituted a new bom sickle cell screening program
that now covers 40,000 infants. Under Dr. Elders' leadership, the number of children
screened in the EPSDT program went from just over 4,000 in 1988 to over 45,000 in
1992.

One of Dr. Elders' most notable and widely praised achievements was the establishment
of innovative school-based clinics in Arkansas, raising the number from one to twenty-six
during her tenure. Linking public schools with the Arkansas health department.
Dr. Elders was able to successfully bring to those who most needed them services that
increased childhood immunization and early childhood screening and reduced teen
pregnancy, substance abuse, sexual abuse, and sexually transmitted diseases.

As Surgeon General. Dr. Elders will bring new focus to health care toward health
promorioo and disease prevention. New initiatives are essential to control infectious
diseases such as tuberculosis and measles. Health promotion is also a priority of Dr.
Elders, including nutritional information, counseling on tobacco and alcohol use, and
education about avoiding injury and violence. She is dedicated to making primary care
available and accessible to all Americans.

The role of Surgeon General requires a forceful and resourceful advocate for health care.
The College believes that Dr. Elders' record supports nomination to this key position.
We encourage you to strongly support her confirmation.

Sincerely,

Paul F. Griner. MD. FACP
President

120

ARKANSAS PTI-1

SMUOmctlBOOH.P<xUr/N. LMc Rock. AR 72114 /<S0i> TSVS247 Sum Pr«.l*« Don Jormson

4312 Ajetmoo. SprtnffM*. A« 727S4
Ptton* (SOI* h) 7si-oeei

b)750-ea5c
July 1993

Th« Bonorable Bill Clinton
President of the United States
1600 Pennsylvania Avenue
BasMngtoo DC, 20500

Dear President Clinton,

la keeping with PTA 'a non-partisan poller, Arkansas PTA strongly supports Br. Joycelyn
Elder* efforts on behalf of the health and welfare of all children.

Daring Dr. Elders tenure «• Arkansas State Health Director, she was instrumental la the
passage of many legislative Issues supported by the Rational FTA each as the School
-Based Health Clinics, these clinics provide services to assy children who, otherwise,
would be denied services such aa family planning, periodic early health screening, dia-
gnosis, end treatment.

In 1991, Dr. Elders vorked' tirelessly, not only during her business boors bur. during ber
personal elate as yell, along with the aany hoars of her staff. In the testing for and
edacatlng the public about the current dangers of lead poisoning In preschool and school
aged children. The immunization of children continues to be en on going personal battle
of hers, which is another issue" that is dose to the heart of FTA.

Daring the 1992 Legislative Session of the Arkansas Central Assembly, Dr. Elders, along
with the Arkansas rzk, formed a coalition to increase the sales) tex on clgerettes with
the- majority of the funds to be designated for children's health services.

Dr. Elders is a tireless advocate for all health issues, especially those relating to
children. One of ber famous quotes is, "All children are at risk of becoming members of
the S-fi Clnb. that Is homeless, hopeless, hungry, helpless, and hogless." It Is up to us
to pat in place those measures that will void that ateafeershlp forever.

Because of Dr. Elders devotion and i nailiai in to children, Arkansas PTA bestowed upon her
the highest honor MA can award, an Honorary Life Membership in Arkansas PTA. Joycelyn
Elders truly cares for children. It is not out of the ordinary for her to drive for hours
to visit with a teenage mother concerning the health of the mother and/or her child.

He have been privileged to have had the opportunity to have worked with Dr. Elders and we
continue to applaud her efforts. We, sincerely, hope that Dr. Joycelyn Elders receives
the necessary support to become Surgeon General of the united States.

Sincerely.

Don Johnson, President

Arkansas PTA

Office of Cevernmental gelations
National PTA

ARKANSAS COWGRESS OF BARENTS AND TEACHERS

CMA

121

CHILD WELFARE LEAGUE OF AMERICA, INC.

440 F.rs< Sue*. NW. Su.ie 310. Washington. DC 2O00I-2O8S • 202/638-29S2 - FAX 202«S38-W04

—aw —

1.1,8.19*3 JuOa^JY i

IT-

The Honorable Edward Kennedy, Chairman .

COBmuBBC on Labor and Human Resources /. / /

U.S. Senate ( / : J^l j

Washington DC 20510

„ *^
Dear Mr. Chainnaa:

S-; **

fAX it X7W*-50rs

Please accept my enthusiastic recommeodatioo of Dr. M. Joycelyn Elders for
the position of Surgeon General of the United States. From my perspective. Dr.
Elders is the ideal candidate for this position

Throughout her long and distinguished career as a physician, public servant,
and children's advocate. Dr. Elders has demonstrated an unwavering commitment
to the welfare of children, youth, and families. Her work as Professor in Pediatrics
at the University of Arkansas Medical Center tmti''af'*"c both a profound concern for,
and extensive knowledge of. the health needs of the nation's children.

She also brings outstanding public leadership credentials to this position. As
director of the Arkansas State Health Department since 1987, she has helped to raise
the inununization rates of pre-school children in the state. Her programs have also
led to a reduction in infant mortality and the rate of increase in teenage pregnancy.
Dr. Elders' service on several national health commissions, including the Secretary's
Advisory Committee for Infant Mortality, means that she will bring a broad national
perspective to the Surgeon General's post.

In addition, her impressive record of civic service, which includes terms as
a board member of the Elizabeth Mitchell Children's Home and Youth Homes Inc.
demonstrates her knowledge of the needs of vulnerable and at-risk children and
families.

Dr. Elders will make a superb advocate for the health of our nation's children
and for enduring changes to improve the health of all Americans. I heartily endorse
her noniination.

Sincerely,

David S. Liedennan

Executive Director

cc: Members of the Senate Committee on Labor and Human Resources

122

WtibUjtoc Buttjuj
NatieoaJ Assoektiea tor die AdvaDcememt.tf Colored People
1025 Vamau Avoau, N.W. Suht 730
Wishing**. D.C -20009 'J-..
r - '■' .'-" f202; ea»-J26^ar #B; £»#*$

^OTON^JtJE^Ck

TO: Interested Persons . DATE: July 7, 1993

FROM: Wade Henderson, Director /\/f\

RE; Nomination of Dr. Joycelyn Elders for Surgeon General

ACTION NEKOED:

Can, write, and send telegrams to your Senators and nrge them to support the
nomination of Dr. Joycelya Elders for VS. Surgeon General. Contact these
members of the Committee on Labor and Human Resources: Edward M. Kennedy-
MA (Chairman), Claiborne Pell-Rl, Howard Metzeubaum-OH, Christopher J. Dodd-
CT, Pad Simon-IL, Tom Harkin-IA, Barbara A. Mikukki-MD. JcfF Bingaman-NM,
Paul David Wellstone-MN, Harris Woff ord-PA. Nancy Landon Kassebau m-KS. James
M. Jeffords-VT, Dan Coats-IN, Jndd Gregg-NH, Strom Tburman-SC. Orrin G.
Hatch-UT, Dave Durenberger-MN. You may reach your Senators by calling the
Capitol Switchboard at (202) 224-3121.

WH£N.J!JEEI>KD:

Immediately. NAACP members are urged to call their Senators and request their
support for Dr. Joycelyn Elders' nomination. It is Imperative that (he NAACPs
vigorons support for Dr. Elders be heard.

Dr. Joycelyn Elders is the Orst African American woman to be nominated for the
position of VS. Surgeon General. Presently, Dr. Elders is the director of the Arkansas
Health Department. In December of 1992, President Clinton selected Dr. Elders as his
choice for IJ.S. Surgeon General; however. Dr. Antonia Novello, outgoing Surgeon General,
requested to remain in position until June 30, 1993. Several conservative groups and
Christian fundamentalists have attacked Dr. Elders because of her progressive views on
health care for all Americans. Leading the attack is the Concerned Women of America,
who call Dr. Elders *a very, very dangerous woman,* and vow to defeat bcr nomination.

123

Dr. Elders graduated from Philander Smith College in Little Rock. She then served as
physical therapist in the Army before earning her medical degree, and a Masters Degree in
biochemistry, from the University of Arkansas School of Medicine. Dr. Elders then trained
in pediatrics at the University of Minnesota hospitals and became chief pediatric resident
at the University Hospital in 1961. For the next 20 years, Dr. Elders combined research in
pediatric endocrinology with a university clinical practice that specialized in the treatment
of juvenile diabetes.

Dr. Elders believes that discussions of "public health" must Include everything from the
impact of poverty, the plague of violence, medical assistance to the elderly, nutrition,
preventive medicine and treatment of disease. In her capacity as director of public health
in Arkansas, Dr. Elders has already battled right-wing forces who opposed her efforts to
combat AIDS, child sex abuse, and adolescent pregnancy through public education. These
groups became particularly angry over her attempts to reduce teen pregnancy and combat
AIDS through school-based dinics and education in public schools. Though personally
opposed to abortion, Dr. Elders is pro-choice.

Dr. Elders* life and career have enabled her to appreciate the harsh realities of health
problems in the African American community, and have led her to tackle hard issues with
vigor. The African American community cannot afford to lose the important opportunity
to have Dr. Joycclyn Elders as our nation's Surgeon General. We need to have a Surgeon
General who is not afraid to speak candidly about the difficult health care problems facing
the nation.

The NAACP must urge Senators to confirm Dr. Elders as U.S. Surgeon General.
Senator Edward (Ted) Kennedy. Chairman of the Committee on Labor and Human
Resources, has voiced his support for Dr. Elders and wQl prove helpful in guiding her
nomination through the confirmation hearings. Dr. Elders' confirmation bearing has been
set for Friday, July 16, 1993.

The NAACP must show a strong, independent voice in support of Dr. Elders. The
African American community, and this country as a whole, needs both her medical
experience and willingness to confront some of the most distressing health problems of our
times.

124

MMidi!
kiuani Gowiameni Allan Ut(«c
BO' I Siren. NW. Soar ?60
Wtehngton. 0C7OU6

few. w m no

f» TIE 796 ?9W

July 14, 1993

The Honorable Edward M Kennedy

Chairman

Labor and Human Resources Committee

U.S. Senate

Washington, D.C 20510

Dear Mr. Chairman:

The March of Dimes Birth Defects Foundation greatly appreciates your
enthusiastic endorsement of Joycetyn Elders, MD. for U.S. Surgeon General As a
pediatrician and a leader in public health, Dr. Elders has been a strong advocate for
improving the health of mothers and babies. Your leadership will be key in securing her
confirmation.

In her capacity as the director of the Arkansas State Health Department, Dr.
Elders has supported and worked jointly with the March of Dimes in our Campaign for
Healthy Babies. She has also helped raise the immunization rates of pre-school children
in the state and has been instrumental in attracting more health professionals to serve
pregnant women and children in the underserved rural areas. Furthermore, she has
forged important linkages between the education and health communities to encourage
comprehensive school health education and to promote the healthy development of our
nation's youth.

The March of Dimes believes that the confirmation of Dr. Elders as U.S. Surgeon
General will help ensure that preventive and primary health for mothers and babies is a
priority of this nation Again, I thank you for your efforts in support of her confirmation-

125

THE ASSOCIATION OF JUNIOR LEAGUES INTERNATIONAL INC.

July 8. 1993

President William Jefferson Clinton
The White House
Washington, DC 20500

Dear President Clinton,

On behalf of the Associarioo of Junior Leagues International (AJLI) it is with great pleasure we
add our support for the nomination of Dr. Joceryn Boers to die position of U.S. Surgeon
General. Through her work as the Director of the Arkansas Department of Health, we have
experienced first band Dr. Elder's vision, compassion, commitment and the difference she has
made in the lives of children throughout Arkansas.

The Assocjatioa of Junior Leagues International is an organization of women committed to
promoting voluntarism and to improving the community through the effective action and
leadership of trained volunteers. Representing 190.000 women in 283 Junior Leagues. AJLI has
over ninety years of experience in working to ensure the adequate health of all children, youth,
and pregnant women. In 1991. the Association's Board of Director's adopted Child Health as
a priority, with the following goal: All children, youth, and pregnant women should be
guaranteed availability and access to appropriate preventive primary health care. The work of
Dr. Elders dearly and effectively supports the Association's position on Child Health and will
bring leadership and attendee to an issue critical to the health of our country. The children of
the United States will be in good hands with Dr. Elders. She will serve us well.

Sincerely,

Mary Burrus Babson Starve McBryde

President President

Association of Junior Junior League of

Leagues International Little Rock

Ervada Ward Janie Coins

President President

Junior League of Junior League of

North Little Rock Fort Smith

660 FIRST AVENUE HEW YORK. NY 10016-3241 212-683-1515 FAX212/181-719G

126

nea

NATIONAL EDUCATION ASSOCIATION

ftilvri Ckuv. v». iv,.iJ. -»i
MiiitIvii MniiulkiH. <■•• •• ••", ■'■■-'

Oi»i C.i'i'Kion buwm".' fV.-.i.«

(.VI I Pill Sl«rl. N'W

ll<iJiin#i«i. IX' 200M> J2<W

I.V2" .s.V 7tW l.n (.W) S22 707-J

EXECUTIVE OFFICE

July 12. 1993

The Honorable Edward M. Kennedy

Chairman

Labor and Human Resources Committee

U.S. Senate
Washington, D.C. 20510

Dear Mr. Chairman:

The National Education Association supports the quick confirmation of Jo/celyn HdejsM^r. as
U S Surgeon General. Dr. Hders has extensive experience and knowlea^jnJjeJieia of public
health and is dedicated to tackling tough issues. While Director of the Arkansas State Health
Department Dr Elders was instrumental in raising me immunization rates of preschool children,
reducing the* teenage pregnancy rate, and belping to lower the states infant mortality rate.

Throughout ber career she has demonstrated an unwavering commitment to improve public health
and has dedicated herself to educating the public on important health issues. As a professor of
pediatrics at me University of Arkansas Medical School and a researcher into the causes and
treatment of hormone-related illness, she published more than 150 articles for medical research
publications She is a board certified r*diatric-endocrinologist. served as a first Lieutenant in the
U.S. Army, and has received the American Medical Associations National Congress on Adolescent
Health Award for outstanding efforts on behalf of American Youth.

America needs strong leadership to help conquer tte ATOS epkwnk. curb ato^ aal drug abuse,
and fight the spread of diseases. Dr. Elders is clearly the person to provide that leadership. lam
confident that as she works to educate Americans on key health issues, she wffl also msprre a new
generation of health care professionals to serve with the same compassion and dedication that she has
displayed throughout her career. We urge you to vote for her confirmation as soon as possible.

Sincerely.

ts&h

Keith Geiger
President

127

YWCA

of the USA.

July 14. 1933

WMMQM 0«e«
6mFtoor

6M9t)S*w(.KW.
WoNngen, DC. 20001

tec 202-713-7 123

Honorable Edward M. Kennedy
United States Senate
Washington, D.C. 205102101

Dear Senator Kennedy:

The YWCA of the US A. •ntnusias&caffy supports President Canton1* nonkufon
of Dr. Joycetyn Bders to the postton of U.S. Surgeon GenersL She is a highly
skffled pediatrician, public health professional, and outstanding advocate for
children. She understands the need for preventative services in regard to
adolescent pregnancy and screenings for cervical and breast cancer, HIV, and
children, ad priorities In the pubic policy recommendations of our constituents.

As a professor of pediatrics and researcher at the University of Arkansas Medical
School. Or. Elders authored more than 150 scholastic articles for medical
pubfcation&. Her oTsSnctJoos include the .American Mecfical Association Awards
for Outstanding Efforts on Behalf of American Youth and for Outstanding Pubfic
Heaflh Professional, the National Education Association's Mary Futre* Award for
Creative Leadership In Woman's Rights, the National Governor's Association
Distinguished Service Award, and the National Coalition of 100 Slack Women's
Candace Award for Health Science.

Confkmaflon of Dr. Elders wO ensure an increased dedication to the health
status of afl Americans. We urge you to strongly support her confirmation.

The YWCA of Vie U.S A is a women's membership organization. Founded m
1858, it is committed to the empowerment of women and the eaminandn of
racism. Currently, It serves over two manon girts, women and their famfies
through 4.000 location* across the nation.

Sincerely.

Ann StaSard

National Preside

GCSsnb

/ Gwendolyn Calvert Baker

y National Executive Director

HateatBoaa

War ftmkun. fcOWi

72SI

N*.*rt.NYtO0O3
212-8 V4-2700

JMST

Z5&

128

General Board of Church and Society 01 The United Methodist Church
100 Maryland Avenue. N.E.. Washington. DC. 20002 • (202)488-5600

July 7. 1993

United Stares Senate
Washington. DC 20510

Dear Senator:

The General Board of Church and Society of The United Methodist Church is proud of Dr. Joycelyn
Elder's commitment to health and wholeness for all. A life-long member of our denomination, she
exemplifies, through her words and actions, the church's dedication to healing ministries. Her career as
a pediatrician and public health professional characterizes her religious devotion to the needs of others.

Dr. Elders has the strength of will and mission to confront the difficult and complex health care issues
facing our nation. As Surgeon General, she win lead us in reform by focusing the debate on the concerns
of prevention and accessibility. One of her major goals will be improving the health and well-being of
alt. especially adolescents. She will address the issues of infectious disease, nutrition, tobacco and
alcohol use. as well as (be prevention of injury and violence. Her leadership, anchored in her faith
commitment, is urgently needed in this era of failing health care systems and polarized vested interests.

/. Elders is a board-certified pediatric endocrinologist. As professor and researcher at the University
<f Arkansas Medical School, she has authored more than 150 scholastic articles for medical publications.

Among numerous distinctions, she has received the American Medical Association's awards for
Outstanding Efforts on Behalf of American Youth and Outstanding Public Health Professional, the
National Governor's Association's Distinguished Service Award, and the National Education Association's
Award for Creative Leadership in Women Rights.

She currently serves on the boards of a dozen councils and commissions in (he public and private sectors,
including (he National Institute of Medicine's Hearth Promotion Disease Prevention Committee and the
Council on Government Affairs for (he Academy of Pediatrics.

In (he five-and-a-half years since she became director of the Arkansas State Health Department, she has
helped raise the immunization rates of pre-scbool children in (he state and has been instrumental in
attracting more health care professionals to practice in underserved areas.

Confirmation of Dr. Elders will help ensure (hat an improved health status for all becomes a priority of
(his nation. I encourage your sfong support in her behalf.

Sincerely,

Jane Hull Harvey

Assistant General Secretary

Minjnrv of God's Human Community

129

Why the Government Urges
Abstinence and Condoms

• Hcaltn: The public interest in
curbing scr-relatcd dtsctcc is also
scrvco in encou rapine moral, or
*u least more responsible,
scx-rclatcd bduvio:.

87 JAMS O. MASON

A cvsk I l— uta ten Ox k»»rr
<40W Out aOf to 4 t*r*Q" ted I
•■=0 aettre tfcer «"••* MMfVll. TV
cacaar — Hal Sua ttoa the t«v.

unafiutattmaliirtidiia

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>»» •*»•— iambi urrt

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ata".

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a* raetk Hoki larlct Out arufa
■ •«« carj« mu

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baft* tr« tut ctaatffK
fartjj fJCCRK « UW llll»»llWl «x «

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lattpoc jtble ««. wttcUter
betYrtMa hoasosustlf or

net era 14jcu*Ii — ti t root canoe
of coirtT of tte dosttu,

dUatblflry end «nf utt* o( AIDS.

T» iuxk^cuU rate a **aa araactx •
Ml a 113 H fMrtM. C TMNB Xacn.

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130

PERSPECTIVE ON AIDS
L-A. Times; 7-20-92

L-A. Times; 7-20-^ ._ _ Tr x 7 , C^ C C\

How Do You Know You re Sate/

Women musi gei serious

about protecting
! themselves, for the

epidemic is spreading,
i especially among teens.

Jlj By »KTOMI* C. H0VEU.0

As the nation's first female sur-
geon general. Id like 10 speak 10
women in this country iboui a
health problem that make* me (ear lor
all of us the alarming spread of AIDS
among sexually aciive women

In the second decade of the eptdeimc.
the female (ace of AIDS if siitl largely
unfamiliar We do not yet see ourselves
from this new and unsettling vantage
point, and we are letting this killer claim
more and more of us and our children

Wf* cannot expect to have any real
power over our health and well-being
until we are empowered with knowl-
edge. If we have learned anything from
if>r soltdantv of the women s movement,
it ts this To know a to care, and to care
■s to act

Let me share with you some facts
about women and AIDS, so thai you
begin to see the problem as it really is

The Centers (or Disease Control esti-
mates that 111.000 women can be count-
ed among the 1 million Americans w-ho
are mfected with the virus but do not yet
show major symptoms Although men
still account for most of the reported
cases of AIDS in the United States,
women and pennatally infected children
are the fastest -growing groups of people
reported Out of more than IK. 000
reported cases, roughly 22.000 have
been reported mi women, almost half of
them mi the past two years

HIV infection and AIDS are now
among the five leading causes of death
(or women 2S to 44. an age group that
account? lor nearly half of all the
women mi tho country In New York
City and New Jersey. AIDS is already
the leading cause of death in women of
ctuldbeanng age.

About half of the women now sack
with AIDS acoutred the virus by inject -
mg drugs, out at least 34*r got AIDS
through heterosexual sex. and n xt this
risky behavior that endangers the
greatest number of women. If we com-
pare the first half of the epidemic u> the
second half, heterosexual transmission
has lumped by 4<% Among teen-age
women the situation i* even

pronounced 50T, of adolc~
eem females oiagnosed wuh
AIDS in 1990 reported con
tracting the virus through
heterosexual conuci

Although thr data on trans
mission through vaginal in.
tercourse are still limited a
number oi studies have sup
- gested that an infected man

may be 2 to a tones more
likely to pass the virus to a woman than
a woman is likely to pass « to a man one
study estimated a 20 tunes higher rut

Any woman who risks hating unprc-
tected sex with fust one man is taking
the incredible risk of exposure to all of
hrs partner; Remember the partners
you have had in the last 10 years, now
think about what that means to you and
your children, even those yet unborn

It ts widely assumed that women who
get AIDS through sex arc part of the
drug culture Indeed. 62*; of women
who acouirr the virus heierosexually
report that their partners injected drug;
But an increasing proportion of AIDS
cases ts being attributed to sexual con-
tact w-ith a man whose nsk factors were
unknown to the woman This category
has increased from 6Tt m I9&1 to about
IS-", in 1391 Also increasing is the
number of cases among women who
report sexual contact with bisexual men
9*i fall into this category, and they tend
to be older women, between 30 and 49

I cannot stress enough the far-reach-
ing, deadly consequences of drug abuse
Drug injection transmits HIV through
Mood in and on shared needles and
syringes Tins pracucr involves a two-
fold nsk direct transmrssMn through
shared needles and sexual transmission
from men who infect drugs Alcohol.
crack cocaine and other drugs alter
judgment about sexual contact and may
put users of these drags a: higher nsk
for infection
We

stop taking chances and
begin to lake greater charge of our lives
We must take the imuauve to protect
our health, to shield ourselves and our
children from all sexually transmitted
diseases, including HIV

The Imsi step in prevention rs being
aware of the nsks. then the challenge is
to change behavior Tho means refrain -
mg from sex altogether, or demanding
and nutfiuinmr a truly monogamous
relationship, or negotiating for safer sex
through the use of condoms

Taking such action can be very hard
for some women v-> uvr been telling
•dually active women thai abstmencr

works and that those v. ho cannot al-
stain shoulo change the ruie« arm
insist that their partners wear ronoom-
But tor women in some communities
this can seem impossible We have also
been telling *ornen that monogamou-
sex with one uninfected partner i-
sale— but reahsueallv speaking can*--,
cry woman be sure that she is in j irul;
monogamous relationship" 8ecausr of
socul cultural and religiou' beliefs m
some communities women who insist on
bargaining for their protection may be
abandoned, abused or thrown out on the
streets

Of equal concern is the fact that nun>
women, especull-- those associated with
the drug culture, are not inclined to seek
health services In many cases women";
inbred role of caretaker leads them to
put others first. They may be diagnosed
too late and thus appear to die faster

AIDS diagnoses may also be compli
cated by the fact that women with HIV
often present slightly different symp
tone Ulan men. Like their male counter
pans, they suffer from diarrhea weight
loss and Pneumocystis carint. pne-jmo
nia In addition to these wrtl-fcnonri
AIDS manifestation', women with the
virus are prone to gynecologici: disor
ders such as cervical dysplasia taonor
ma: cells of the cctvui and severe
difficult -to -treat yeast infections O- ■
ing to these gender differences in the
manifestation of the disease. I urg<
women to consul: thoroughlv with their
health -care providers

Woman to woman. I urge each of >ou
in all sincerity, tha: if you have an>
reason tu believe tha: you may ha»<
contracted HIV. the time to ae: •; <*w
Contact your doctor or visr. * publrc
health clinic or testing site ngh: a«a
(or counseling anc testing

And don t panic Remember, you art
not alone. AIDS has become - womer •
disease Lntr! there ts a cure. «e muv.
encourage one another to ou »tui ••
necessary to take care of ourseivcr !• :■
net egotistica: to give our own hcalir.
pnoray ■ n is Me -affirming In ihe face of
AIDS, for once put your owr. heal:::
lirst Your family will have a lifetime «.
be glad you did

For more information. ca:i the Center-
for Osease Control fvatMWia: AIDS Hoi
hne 1-800 312 -AIDS, or 1-300-344
SI Da t Spanish i

Lr Antonio C \ourV • i< th>
ornnal ol thr I nttrd 2Uotr>

ivr<yr,.

131

Teen-agers' high-risk
behavior courts ADDS

COMMENT

By Aranoin C
Novwlo, sur-
geon fshrnvaj
c4 ire PuCfic
Haalm Service

While AIDS experts cortter in Amsterdam, the
USA needs to focus on curbing the spread of
the virus among adolescents.

The fresh young Bases of our every 30scc-
adolcsccne are iacreastagly oods.
becoming (be new faces of Young
AIDS — and as a oaoon we people crura
na-r not yet begun to recog- understand
"•■"• that tsa. Ok links m

The plan truth ts that today. Ok chain of
in tbis country, rruluoas of high aloobol cad
setMOl and coucge-age SBKieos other drugs,
may be at dire risk of contract- risky sex
tag i£< buman irnrnunodefi- practices,
oency virus and AIDS. multiple as

Through June, S72 cases of partners. ta>
■dOlccePB with AIDS were re- protected
ported in tbe UpJtad Srafrt sex aod ser.-
Tbo deceptively small ouraber
ooaoaq tbe tact that over
44.000 young adults ages 20-29
have been reported wta» AIDS,
many of auuut may Daac PI t a
uuccied during then- teenage
years, la 1989. HTV/AIDS bc-
came tbe sua leading cause of
death among young people
ages ISM

AIDS cues i»|""«*v< **rwig
artolrrrm females have mare
than doubled — from 13% of
aO artotrrrnt cases hi 1987 to
X% in 1991 — and more (ban
half are doe S3 bcocrosexual
cocoa. While (he overall raoo
of males, to females reported
vifh AIDS is I to I In adutts. tt ts
2.7 to | amoog teen-agers.

Studies indicate the —crag
age of arst sexual expenence
amoog US. adolcsccnc b 1 4 A
1990 survey of adolescents by
tbe Centers for Disease Control
reported that 14% were sexu-
ally active before notsbiog
tugh school and 19% bad lour
or more partners.

1 must so ess this c usually
unprotected v i ital acoviry Of
Ok students surveyed woo bad
so to tbe three prcccdint
months. <i% reported using
condoms. Coooom use dropped
ojxtlftcanay as age increased

Also. S mllbon cases of sexu-
ally transmitted diseases occur
annually among persons under
tbe age of 25 — tbe equivalent
.. Of a tccn-agcr contracting ■
menially rransrraacd debtee

ually transmitted diseases

wtuch can lead u> rrarramrrrtoo
of BTV and AIDS. Too many
young people fan to racagaja
these risks and f*ilm prof es-
s»ooal ginrtaorx and sappon. 01
(he adolen PBB arho did sock
AIDS/HTV cnyjixliug and test-
ing bra year, futrr b«% <&d oo<
recta' o lor Oaerr lest tmfci

AS snrgeon general. 1 cannot
allow the jpread of HTV m ado-
lesceots to coolloae un-
checked We most Impress
upon ooa* young people Qhnf ab-
stinence ts the ooly suit way to
protect thepssBTvcS from nc-

disoase or HTV. Bat being real
isoc 1 believe «e must also
crtucati* oar youth about the
best ways to protect fhexn-
idvo U they cboose to be sexu-
ally active. Fortbcm. we mus
not fail to provide adequate a>
■TfwSBMQ oo correct use of coo-
donas and alert tbem to their
obligations and lesponnhilitics
toward oteh- sexual partoers.
Above all. we must foster In
tbem a cauoous, sensible and
rcalisoc approach to sex

As canag adults, we must
empathise wttb youth and re-
member that most of tbem «ali
and themselves In rtsfcy soia-
oons tasting for perhaps no
more than a few minutes but
having perhaps a liteome of
consoQuenccs.

Health-care providers and
government officials have to

Who is getting AIDS

Cases by age o>-wgh June ieso

job m d-y-as-t-

tJUHfeiil

How teens contract it

Iroaacing nurntsars of Mans am at nak. eWakoown oy
cassgonos in 13-19 ago group. (Through Juno 1992)

MiMsxtorava
aax «Mi makes
Iryacong drugs

213

24n.pjpjQ

" mm

Maine wno hava
aax whri masas and

raact drugs

4%|

IHsmopruW
Coagulation ocsorowr"

267

.vxfgpjrg

HaMrosnxual conraa

124

14% |

FkKspwrt of t*»3

uumpuiaaaj ornssua _

■ '

How teens rate AIDS

GnJbp survnynrj mora Plan
500 wan agancoBW most

9aan ganaraaon. Soma atans
ravnad mora fnatn coo probtam

Drugacaaa 49%

Pwarpraaavn 1ST.

AIDS 11%

agnancy 0%

Alcohol abusa 7%

Bout aaatl 7%

deal wan complex problems
wncnancitaxingtonalanr-rpa-
renal rights with (he 001000-
my of the young person. Issues
bke consew to be tfgrrl. ooaa-
caooo of uuuots who test pos»-
Qve. aod dnrtrrairc of results to
parents and/or sexual aod
drug partners who may be at
rok wui have to be addressed
— all-'wbile w B> ning coal
oconaury. »c roust ensure thai
adotesccno have access to vest
uig aod couoscuog that S>ey
wuj feel comfonable going 10

Tbe unporrancc of raouvg
adolcsceocs' awareness of tbe
dangers o< KIV/aIDS cannot
be overstated. But we must be
wvtchful that our strugs^c to
educate tnem rs not rendered

boOow by failure to provide bo-
mane, respectful andconaden.
oalsennces to all adolesoena.
Tbe success or failure of our
< Sorts to address KTV uMccsoa
In adolcsccno depends less oo
tbe cornpooenrs of our uuoa-
pves (ban on the willneeocdu}
"carry them out. We cannot per
nut tbe ulxuTtatdy divisive c-
sucs of adoleacenf develop.
meat to hinder our cflorrs. Tbe
ome has come u> open our eyes
10 tbe chanpog faces of AIDS,
to do away with blame and to
share msxead. In rbe wisdom
and experience (hat ~ui pn>
tect our cblldncn — and theirs
— (rom Ove enagedy of AIDS

»■ AIDS coniorvx-ice llv'O

132

Otl'AKTMtNl Or III. ALTM S HUMAN ^ERVtCtS '•.">,< '■"••>'l'>S.-.v.c,

Ci'<i)e<-. I» O.-.rj-,.- Co"l.ol
Ahj.mjCa 10333

I? I 5

The Honorable Edward M. Kennedy

Chairman

Committee on Labor and Human Resources

United States Senate

Washington, D.C. 20S10

Dear Mr. Chairman:

You have inquired about the use of Centers for Disease
Control (CDC) sexually transmitted disease (STD) and human
immunodeficiency (HIV) prevention funds, for condoms. When asked,
we have provided the following guidance:

The Centers for Disease Control (CDC) supports public health
activities that can prevent the spread of human immunodeficiency
virus (HIV) infection among adults and young people. Prevention
messages targeted to these populations strongly emphasize
postponing sexual activity for young people, and mutual monogamy
with an uninfected partner for sexually active adults. From a
public health perspective, both approaches will help prevent
infection with HIV or other sexually transmitted diseases (STDs) .
For those persons whose sexual behavior puts them at risk, proper
use of condoms is an effective means of reducing the risk of HIV
or STD infection.

Cooperative agreements with state education agencies funded
by CDC's Division of Adolescent and School Health are used to
support HIV education as part of comprehensive school health
education. These programs are designed to help young people
develop the skills they will need to avoid HIV infection, other
STDs, and other related health problems. These cooperative
agreements provide support for the implementation of HIV
education within comprehensive school health education programs,
but not for the purchase or provision of condoms.

The CDC also supports state and local health departments as
well as community -based organizations to implement HIV prevention
programs. These grantees are authorized to purchase condoms with
funds awarded to those agencies by CDC. These funds are
different from those awarded to state education agencies. Health
departments are authorized to use funds from both the STD grants
and the HIV prevention cooperative agreements for purchase of
condoms, for distribution in STD clinics or as part of ocher
health department programs.

Decisions about the role of condoms in any program of HIV
and STD prevention are best made locally, with careful attention
• to the context in which they are presented. The CDC recognizes
and supports the right of each affected community to determine

the course of action most appropriate co prevent HIV inici .on
under local circumstances.

I hope this information is helpful to you.

Sincerely,

William L. Roper. M.D. , >1.P.H.
Director

133

COHDOXS TOR PBSVEWTIOU OT STD/HIV

Overview

• Bacteria and viruses cannot pass through an intact latex condoc

• Multiple studios have deaonstrated that condom use protects against STD
. Several etudles in persons continuously exposed co HTV+ partners show chat

condoms procecc than against HIV infect: ion

• Contraceptive failure rates are very low aaong experienced users

• Condons ire manufactured with high star.dcads of quality

• Breakage rates attributable to poor quality are very low

Sf faotiveness
Laboratory studies

• Condoms provide a mechanical barriar which prevents dlrecc contact with

semen, ganlcal discharge, genital lesions, or infectious secretions

• Bacteria and viruses cancot pass through intact latex condoms

• Viruses occasionally pass through natural aeabrane ("skin" or lambskin)

condoms under laboratory conditions

Human studies

• Multiple studies show condoms protacc users and their partners against
gonorrhea and infection with ureaplasaa, herpes simplex virus, and HIV

• Several studies show 1001 effectiveness against STD and HIV

Condom Quality

• Condoms are classified as a medical device regulated by the FDA

- Condoms are manufactured according to national standards

• Each condom is individually tested for pinholes and areas of Chinning

Condon railure
Incorrect use or oocuse

• Condoms are highly effective only when used consistently and correctly

- Most experts agree that condoms fail eosc often due to incorrect and/or

Inconsistent use

• Typical contraceptive failure rates of 10-201 include persons who did not
use condoms consitentLy

• Studies show that only 30-601 of mao who claln to use condoms for
contraception actually used them for every act of intercourse

• Contraceptive effectiveness increases with experience-- failure rates as low
as 0.61 nave been documented in experienced users

Condom breakage

• Most studies in the U.S. show breakage rates i» leas than la (1 break per
100 acta of Intercourse

• Incorrect use (oil -based lubricants, fingernail tears) accounts for many
condom breakages .«

• Broken condoms do not always lead to Infecciou or pregnancy- -one study
showed that more Chan half of breaks occurred prior to ejaculation

Thank you for your recent Inquiry regarding ef fectjv«>nwss of condoms to
prevent sexual transmission of HIV. Enclosed ace a bibliography of references
and a review from the Morbidity and Mortality Weekly Report.

Condoms provide a mechanical barrier which prevents direct contact with semen,
genital discharge, genital lesions, or lntectious secretions. To be effective,
condoms oust be placed on the penis prior to any genital contact, must remain
intact, and. most importantly, must be used consistently and cocrectly.
Effectiveness of condoms to prevent sexually transmitted diseases has been
documented in many laboratory and clinical studies.

134

Multiple laboratory studies, some of which attempted to simulate the
mechanical friction of coitus, have clearly demonstrated that a latex condom
is a continuous, impervious barrier to sexually transmitted bacteria and
viruses, including HIV. Natural membrane ("skin") condoms, however, have been
shovn to contain small pores which allow passage of HIV in laboratory tests.

Multiple studies conducted among sexually active persons have shown that
condoms protect users and their partners against gonorrhea, ureaplasma
infection, herpes simplex virus infection, and HIV infection. As with
contraceptive studies, effectiveness varies among studies- Several studies
show 100Z effectiveness, but others show that some individuals became infected
despite self-reported condom use. Some of these individuals may have become
infected prior to starting consistent condom use. Condoms are highly
effective only with consistent and correct use. which cannot be easily
confirmed by researchers. Condom failure is due to nonuse. incorrect us«.
breakage, or leakage. Although the 'typical- faiUre rate of condoms as
contraceptives Is approximately 10-20Z, this figure reflects failure of the
user (to use the condom) in addition to failure of the condom itself. Indeed,
condom effectiveness as a contraceptive increases with experience, and failure
rates as low as 0.6Z have been documented (Vessey) . M°st **** suggest that
the individual, not the condom, is usually responsible for infections and
unwanted pregnancies, and inconsistent use accounts for a large proportion of
unwanted pregnancies among condom users (Sophocles). For example, studies in
Bangladesh (Ahmed 1990). and Barbados (Russell-Brown) showed that only 602 and
30Z. respectively, of men who said they used condoms for contraception
actually used then for every act of intercourse.

Incorrect use also accounts for some cotiduu failures and breakage. In one
study, men who acquired gonorrhea despite condom use reported putting the
condom on the penis after sexual activity had begun (Darrow). Most studies in
the United States have shown breakage rates ate less than 1 break per 100 acts
of Intercourse, and Incorrect use accounts for a lacga proportion. One
Australian study (Richters) reported 8 breaks In 1269 acts of vaginal and anal
sex (•■« rate of 0.6Z); seven of the breaks were related to fingernail tears or
use of oil-based lubricant (which weakens the latex).

Manufacturing defects are quite uncommon, since national standards are used
and samples are tested to assure high quality, tech condom Is individually
tested for pinholav or areas of thinning. Moreover, condoms aro classified as
medical devices by the Food and Drug Administration, which actively monitors
condoms manufactured in and imported into the United States.

It is important to remember that a broken condom does not always lead to
pregnancy or infection (Liskin). A woman's chances of pregnancy from a single
act of intercourse have been estimated to average 2-«Z (Tietse). In one U.S.
survey, pregnancy occurred in only « of women who reported condom breakage
(Hatcher). Although infection with a sexually transmitted disease can occur
at any time, most exposures do not in fact lead to infection. The chances of
infection with HIV after a single sexual exposure has been estimated to be as
low as 0.001 and as high as 0.1 (Liskin). also, not all condom breaks are
equally risky. In one study (Piedrahita). more than half of the breaks
occurred while the condom was being put oa or taken off. In another study,
all breaks occurred prior to ejaculation (Richters)

In summary, we regard condom use as "highly effective" for the following
reasons: (1) bacteria and viruses cannot pass through intact latex condoms,
(2) multiple studies have demonstrated that condom use protects against
sexually transmitted diseases. (3) several studies have shown that persons
exposed to HIV who used condoms remained free of infection over many months,
(4) extremely low contraceptive failure rates have been demonstrated among
experience condom users. (5) condoms are manufactured with high standards of
quality, and (5) breakage rates attributable to poor quality are quite low.

1 hope this information is useful. Thank you for your concern about this
important public health Issue.

135

References

Renew Article*

Canters for Disease Control. Condoma for prevention of sexually transmitted
diseases. MMWR 1984:37:133-137. (19 rafarances]

Peldblum PJ , Fortney JA: Condoms, aperaicides, and the transmission of human
immunodeficiency virus: A review of the literature, ajpb 1988,-7BiS2-54.

Crimes DA, Cats W. Family planning and sexual Uy transmitted diseases. In:
Holmes KX, March P-A, Sparling PF, et al. eds. Sexually transmitted diseases,
second edition. Hew York: McGraw-Hill. 1990:1087-94. (99 references]

Batcher RA, Hughes MS. The truth about condoma. SXECUS Report 1988;17:1-9.

Liskin L, Wharton C, Blackburn R- Condoms-How more than ever. Pop Reports,
Series H, Mo. 8, 1990. (437 rofereneae]

Stone Xatherine M. Avoiding sexually transmitted diseases. Obstet Gynecol Clin
H America 1990;17:789-799. (74 refereecee]

Stone XK, Crimea DA, Magder IS: Personal protection against STD. Am J
Obstet Gynecol 1986; 1SS: 180-188.

3tone XM, Orlmes DA, Kagdec LSi Primary pc«v«ntion of sexually transmitted
dieeeaea. JAMA 1986, 2SS : 1763-1766.

Condoma for Pievsntirm of STD

Laboratory studies

Contat MX, Hardy D, Sern&tinger J, Spicer 0, Levy JA: Condoma prevent
transmission of AID£-associated retrovirus. JAKA 1986 i 2SS: 1706.

Coaant MA, Spicer DM, Smith CD: Herpes simplex virus transmission i Condom
studies. Sex Tranem Die 1984;11:94-9S.

Judson FN, Shret JM, Bodin CF, Levin MJ, Rietmeijer CAM: In vitro evaluations
of condoms with end without noaoxyaol 9 as physical and chemical barriers
against Chlamydia trachomatis, herpes simplex virus type 2, and human
immunodeficiency virus. Sex Transm DLs 1989;16:S1-S6.

Katsnelson S, Drew WL, Mintz L: Efficacy of the condom as a barrier to the
transmission of cytomegalovirus. J Infect Dis 1984; ISO: 15S-1S7.

Klsh 13, McHahon JT, Sergfeld WT, Pelachyk JMr An ancient method and a modern
scourge: The condom as a barrier against herpes. J Am Acad Dermatol
1983;9:769-770.

tlinuk cr. Bohme CZ, Bowen TJ: Ooado— and hepatitis a virus. Ann Intern Med
1966; 104: 584.

Hinuk, Ci, Bohme CX, Bowen TJ, Boar DL, Caasol S: Condoms and the prevention of
AIDS (latter]. JAMA 1986; 25*; 1443.

Minuk CT, Bohme CX, Bowen TJ, Hoar DL, Caasol S, Gill MJ, Clarke EDC: Efficacy
or commercial nodosa in the prevention of hepetitLe B virus infection.
Cemtroenterol 1987;93:710-714.

Reltjmeijer CAM, Krmbs JW, Peorlno PM, Judson FN: Condoma as physical end
chemical barriers against human immunodeficiency virus. JAMA
1988;259: 18S1-18S3.

Van de Per re P. Jacobs D, Sprecher-Coldberger S: The latex condom, an
efficient barrier against sexual transmission of AIDS-related viruees. AIDS
1987;1:49-52.

Cl intcaJ Studies

Allen S, Linden CP, Hulley S. Garael K, Black D, Coates T. Behavior change
among HIV- and HIV«- urban Rwandan women. Presented at NIMH workshop on HIV
Prevention and Behavior Change, Washington, DC, April 4, 1991.

Darrow, WW: Condom use and use-effectiveness in high-risk populations. Sez
Transm Dis 1989;16:157-160.

Fischl HA, Dickinson GH, Scott CB, Klimas B, Fletcher MA, Parks W: Evaluation
of heterosexual partners, children, and household contacts of adults with
AIDS. JAMA 1987;257:640-644.

Kemanga n, Ryder RM, Jingu M, et al. Evidence of marked sexual behavior change
associated with low BIV-1 seroconversion in 149 married couples with
discordant Hiv-l serostatua: experience la an HIV counseling center in Zaire.
AIDS 1991;5:61-67.

136

Laurian r. Peynet J. Verroust F: HIV infection in sexual partners of HIV
infection in Mxuel partners of HIV seropositive patiente with hemophilia. K

Engl J MCd 1989; 320 : 183

man j, Quinn TC, Piot P, et »1: Condom u«» and HIV infection among
prostitutes in Zaire. N Engl J Had 1987;316:34S.

Hgugi EM, Plummer FA, Sunonsen JH, at. al: Prevention of tranamiasion of human
usmanodaf iciency rixui in Africai Effectiveness of condom proaotion and
health education among prostitutes. Lancet 1988. -2 :887-B90.

Oberle HW, Rosero-Bixby L, Lee FK. Sancbez-Bcaverman M, Nahmlu AJ, Cuinan HE:
IMrpoa simplex »lru« type 2 antibodies: High prevalence in monogamous woman
in Costa Rica- Am J Trop Med Hyg 1989;41:224-229.

Padlaa H: Ma le-to- female tranamiasion of HTV [latter]. JAMA
19B7;2S8:3386-3387.

Padiaa H, Karquia L, Francis DP, Anderson RE, Rutherford CM, O'Mallay PM,
Hinkelstein W: Male-to-female traaamiaaion of human immunodeficiency virus.
JAMA 1987;258:788-790.

Feterman TA, Stoneburner RL, Allen JR. Jaffe HW, Curran JW: Risk of human
immunodeficiency virus transmission from heterosexual adults with
transfusion-associated infections. JMO\ 1988;2S9:SS-S8.

Quinn TC, Clasaar O, Cannon RO, et al: Human immunodeficiency virus infection
among patients attending clinics for sexually transmitted diseases. N Rngl J
Med 1988,-318:197-203.

Rosenberg MJ, Rojanapithayakorn H, Feldblua P, Higglns JEi Effect of the
contraceptive sponge on chlamydial infection, gonorrhea, and candidiasis.
JAMA 1987;257:2308-2312.

Roumalioutou-Karayannis A, Kestoridou K, MandalaJci T, Stetanou T, ..
Papaovangelou C: Heterosexual transmission of HIV in Greece. AIDS Keeearch
and Human Retroviruses 1988;4 : 233-23S .

Smiley KL at al: Transmission of human imannodeficier.cy virus to sexual
partners of henophll iaca . Am J Hematol 1988;28:27-32.

Smith OL, Smith RT: Lack of HIV Infection and condon use in licensed
proatitutee. Lancet 1986; iii 1392 .

Cemmnm Oval it y/ Breakage

Albert AE, Hatcher RA, Graves W. Condom use and breakage among women ln a
municipal hospital family planning clinic. Contraception 1991 ; 43 i 167-76.

Flodranlta C, Blnson K, Poldeay R. Stainer M, Joanis c. Latex condom breakage
study, Barbados and St. Lucia condom lot, sitei Family Health International
(PHI). Research Triangle Park, HC. FBI, September 1990 (unpublished) .

Consumers Union. Can you rely on condoms? Consumer Reports March 1989.

Free HJ et al: Relationship between condom strength and failure during use
Contraception 1980 ; 22 t 31.

Free KJ et al: An assessment of burst strength distribution nets for
monitoring quality of condom stocks in developing countries. Contraception

1986j33t2BS.

colombok s, SAetchly J, Bust J: Condom failure among homosexual man. J AIDS
1989;2:404-409.

Program for Appropriate Technology ln Health (PATH) and Program for
Introduction and Adaptation of Contraceptive Technology (PIACT). Monitoring
condom quality. Outlook. 1987;Si2-S.

Richters J, Donovan B, Cerofi J, Watson L: Low condom breakage rate in
commercial sex. Lancet 1988;2:1489.

Tlndall B. swar.se* c. Donovan B. Cooper DA.: Sexual practices and condom usage
in a cohort of homosexual men in relation to human immunodeficiency virus
status. Mad J Australia 1989;151:318-322.

vanCriensven CJP, devroome EMM. Tielman RAP, Coutinbo RA: Failure rate of
condoms during anogenital intercourse in homosexual man. Cenitourin Med
1988;64:344-346. ^^

137

voeller B, Coulson AH, Bernstein CS, mLuuci RMz Mineral oLl lubricants cium
rapid deterioration of latex condoas. Contraception 1989;39:96-102.

Migersaa L, Oud R: Safety And acceptability o£ condoas for aM by homosexual
men as a prophylactic against transmission of HXV during anogenital sexual
intercourse. Br J Had 1987,-295:94 . (ROTE: Data in text are correct; tablaa
axe wrong J

Oopdfl— for Prevention of Pregnancy

Ahmed C, Liner EC, Williaawon KE, Schellstsda up. Character iatica of condoo
use and associated problena: Experience La Bangladesh. Contraception
1990;42:523-33.

Russell-Brown P, Townseod JW. Study of th« determinants and quality of condom
use in two Eastern Caribbean countries: Barbados and St. Lucia: Final
technical report- Mev York: The Population Council, 1990 (unpublished).

Sophocles AJ, Brozovich EM. Birth control failure aoong patients with unwanted
pregnancies: 1962-1984. J Fan Practice 1986;22:45-8.

nctic c. Probability of prvgnancy resulting from a single unprotected coitus.
Fertility and Sterility 1960;llx48S-8.

Trussell J, Koet K. Contraceptive failure in the United States: a critical
review of the literature. Stud Faa Plans 1987;18:237-283.

Trussell J, tlatcher RA, Cates H, Stewart FH, Koet X. Contraceptive failure in
tba Onited States: an update. Stud Faa Plana 1990;21:51-4.

vaseey MP, Vi Hard-Macintosh L, McPbsrson K, testes 0. Factors influencing
use-effectiveness of the condoo. Br J Faa Plann 1988;14:40-3.

138

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141

Statements of Support for Dr. Joycelyn Elders Received by Senator
Paul Wellstane as of July 23, 1993

Adolescent AIDS Program

Becker, MH (Individual)

AIDS Action

AIDS national Interfaith network

AIDS Service of Dallas

AJ Congress

fcmericaii Academy of Child and Adolescent Psychiatry

American Assoc- of University Women

American Cancer Society

American College of Physicians

rican College of Preventive Medicine
ican Dietetic Association

ican Federation of labor and Congress of Industrial
Organization
Lean Heart Association
American medical Women's Association
Ambulatory Pediatric Assoc.
American School Health Association
American Social Health Assoc.
American Society for MtxHr-jti Technology
American Public Health Assoc.

Association of Maternal and Child Health Programs
Association of Schools of Public Health
Association of State and Territorial Health Officials
Association of State and Territorial Directors of Nursing
Catholics Speak Oat
Child Welfare League of America

Citizen Action

Coalition of Labor Onion Women

Coalition for Hutrition Services in Health Care Ref om

Commissioned Officers Assoc of O.S. Public Health Service

The Council of the Great City Schools

Municipality of Anchorage Dept of Health and Human Services

Englewood Health Dept

Dili 1 1 wim nr ill Defense Fund

Education Training Research

The Faculties of Graduate Programs in Public Health Hutrition

Family Planning Council, Inc (Los Angeles Regional)

State of Georgia Governor's Special Council on Family Planning

International Onion, United Automobile, Aerospace & Agricultural
Implement Workers of America - DAW

<iw» interreligious Response

national Abortion Federation

Rational H— mil 1 ji AIDS Partnership

Mercy medical Center

Mississippi Conference on Social Welfare

national Association of Social Workers

national Association of State Boards of Education

national Coalition to Support Sexuality Education

national Public Health Information Coalition

national Medical Association

142

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY THE

SENATE COMMITTEE ON LABOR AND HUMAN RESOURCES

JULY 28, 1993

M Joycelyn Elders, M.D.

810 Marcia Cove

Little Rock, Arkansas 72206

July 29, 1993

The Honorable Edward M Kennedy
Chairman

Senate Labor & Human
Resources Committee
315 Russell
United States Senate
Washington, D.C 20510

Dear Senator Kennedy:

Attached please find my responses to the written questions submitted by
Senator Dan Coats, Senator Nancy Landon Kassebaum, Senator Judd Gregg, Senator
James M Jeffords, yourself and Senator Paul Wellstone

Attachment

143

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY

SENATOR DAN COATS

ABORTION

1. What is your position on abortion?

A: I have repeatedly stated that I am not about abortion. I believe in preventing
unplanned, unwanted pregnancies. If you do that, then there would not be a
need for abortion. However, I do believe in a woman's right to choose as set
forth in the US. Supreme Court decision of Roe v. Wade.

2. Do you believe a woman should have a right to an abortion, for any or no reason,
throughout the entire duration of pregnancy?

A: See response to 1 above.

3. Do you support reasonable restrictions on abortion such as parental consent or
notification for minors?

A: It is my understanding that the Administration opposes any Federal attempts
to limit access to abortion through mandatory waiting periods or parental or
spousal consent requirements. The Administration does not oppose State
efforts to require some form of adult counseling or consultation for underage
girls who choose to have an abortion — as long as workable and effective
bypass provisions are attached to such laws.

I fully support these views.

4. What is your position on the Freedom of Choice Act?

A: I support the principle embodied in the Freedom of Choice Act which would
codify the tenets of Roe v. Wade. It places priority on the health of women,
which is the standard by which any effort to regulate abortion must be
measured.

5. Do you support the "Hyde" amendment which prohibits the expenditure of
federal funds for abortion except in those cases where the mother's life would be
endangered if the fetus was carried to term?

A: The Administration does not support the "Hyde" amendment and is
working with congressional leaders to facilitate an approach that is
consistent with both Federal and State law.

My views on the Hyde amendment are consistent with the Administration's
position.

6. What is your position on RU-486?

A: I believe that we should work to make RU-486 available to women in the
United States when it is proven to be safe and effective. However, I
understand that a number of steps must be taken before an application can be
filed, and FDA approval can be achieved.

144

7. Is it true that you once described pro-lifers as "very religious non-Christians"
saying, "Yeah, they love little babies, as long as they're in somebody else's uterus"?
(Washington Post, 2/16/93)

A: As I stated during the hearing, I probably referred to them as "the right to life"
groups since I do not use the term "pro-lifers" and I probably called them the
"very religious non-Christian right"

8. Is it true that you later said pro-lifers don't support programs to help children
because they believe: "... a baby is God's just punishment for fornication?'' (Los
Angeles Times, 3/8/93) And that you authored an article appearing in the Berkeley
Women's Law Journal in which you wrote: "We have refused to make a
commitment to solving the crisis of teenage motherhood because we view
pregnancy as just punishment for the sin of premarital sex?"

A: The Los Angeles Times quotes me as saying: "Most of our society believes a
baby is God's just punishment for fornication. Their attitude is, I'm not
going to invest in this baby growing up healthy, educated, motivated and
with hope. I'm going to keep using him to grind in that punishment for
you."" As I stated during the hearing, I believe I restricted it to a narrow
group.

The quote from the law journal article is accurate.

9. Did you also refer to persons who disagree with your position on abortion as
"non-Christians with slave-master mentalities"? (American Medical News, 1/11/93)

A: To the best of my recollection, I never made such a statement

10. At a pro-choice rally did you tell pro-lifers to: "get over their love affair with the
fetus and start supporting the children?"

A: As I responded during the hearing to this question, I did make this statement
The reason I used the reference of the "love affair with the fetus" is because I
look upon it as an affair, a short-term commitment; whereas when a child is
bom, it is a lifetime commitment

11. Did you refer to the Catholic Church as being a "celibate, male-dominated
church?" (Arkansas Democrat Gazette, 1/19/93)

A: Yes. I made the statement in referring to groups fighting the Roe v. Wade
issue. After this statement drew some attention in the media in Arkansas, I
went to meet with Bishop Andrew McDonald to explain that I did not have
any preconceived malice or intent to blaspheme the Roman Catholic Church.
It was agreed that in the future I would refer to the church as "male-
governed" rather than "male-dominated." I later sent a letter of apology to
Bishop McDonald to that effect

12. During a December 30, 1992 interview with Bryant Gamble you are quoted as
saying that you don't feel any of us are "good enough, know enough, or love
enough to make the abortion decision for anybody else."

Yet you have previously stated that as a physician to diabetic teenagers you decided
that if you wanted to keep those kids healthy you "had no choice but to take
command of their sexuality at the first sign of puberty. I'd tell them, "You're gonna
have two good babies, and I'm gonna decide when you're gonna have them.'"
(New York Times, 10/15/89). Could you please explain that statement?

145

A: As I explained during the hearing, these two statements were never stated
together.

The first statement accurately reflects my personal opinion on the abortion
issue Mr. Gumble had asked me about my beliefs on abortion.

The second statement concerns my work as a pediatric endocrinologist with
juvenile patients with insulin-dependent diabetes. It was in this work that I
recognized the importance of being candid with the patient and their parents
about sexual matters. A diabetic female is a hazard to herself and her
offspring if she becomes pregnant at too early an age, before her runaway
endocrine system has stabilized and her diabetes is in good control. I wanted
to help my patients have healthy, happy babies when they were medically
ready to have them. This statement concerned family planning, not abortion.

13. If medicaid does not pay for abortions, does not pay for family planning, but pays
for prenatal care and delivery, that is equivalent to saying that "I'll pay for you to
have another good, healthy slave, but I won't pay for you to use your brain and
make choices for yourself..Jt's a way to keep people poor, ignorant and enslaved. If
your are poor and ignorant, your are a slave." Would you please explain what you
meant by that statement? (American Medical News, January 1993)

A: I am a proponent of access to family planning services for poor women and
preventing pregnancy. We as a nation focus time and resources on health
care for pregnant women and their children, yet do not focus enough on
preventative health measures such as family planning that can assist women
in planning or delaying their pregnancies until they are best able to care for
their children.

14. Many of us feel a great sense of sorrow at the prevalence of abortion in our
society. We understand how difficult a choice it is for many women, and also
recognize how this decision can permanently affect the rest of their lives. Most
believe abortion is an unfortunate occurrence. Yet you stated during your testimony
before this committee on the Freedom of Choice Act that "In the 17 years that
abortion has been legal nationwide, it has had an important and positive public
health effect" Do you really believe abortion has had a positive effect?

A: After I made that statement, I explained my reasoning: abortion is extremely
safe; now that abortions are legal, women are having them earlier - thus,
more safely; and abortion provides an option to families at high risk for
genetic defects. I concluded my testimony by stating that "it is an important
component of a comprehensive public health strategy to protect and promote
the health of women _. the standard by which any effect to regulate abortion
must be measured."

Let me reiterate that abortion is pail of a comprehensive health strategy for

women.

15 During your 1990 testimony before this Committee on the Freedom of Choice
Act you commented: "Many families at high risk are willing to become pregnant
only because of the option of abortion. Further, abortion has rfrinflfl thf numt>er gt
rhnHron afflicted with severe Hofp^- the number of Down's syndrome infante in
W^hinptnn state LP 197ft was 64 percent lower ftM it WOUM JBM^ff0 W|th°Vt
IfigaJ abortion. (FOCA hearing, Hders's prepared statement. May 23, 1WUJ.

146

In response to this statement the National Down's Syndrome Congress has
expressed concern and believes statements of this sort "raise some important

questions in our minds as to her qualification for the position of Surgeon General

It would appear from her testimony and written statements that her concern is
more toward the cost of an individual's life as opposed the value of the human life.
It would not be a good choice to have the Surgeon General of the United States of
America espousing such ideals."

Do you really believe, as your statement appears to indicate, that abortion has had a
positive effect in that it has reduced the number of children with Down's Syndrome
and other severe defects?

A: As I stated at Friday's hearing, "As a physician, I value all human life." I very
much support these children and their families. As a doctor I have cared for
Down's Syndrome children, and I have a beloved Down's Syndrome
nephew. I know that these children are delightful and lovable - and that
they thrive in families who have the resources and wherewithal to care for
them.

However, I was testifying for the Freedom of Choice Act - and I feel strongly
that ail parents should have the choice in this instance. I am not wise
enough, I am not good enough, and I cannot love enough to make this choice
for them.

16. Would you explain what you meant when you said: "Abortion was the single
most important factor in the significant decrease in neonatal mortality between 1964
and 1977"?

A: I was citing information from a 1981 article in Family Planning Perspectives
that found that "increased availability of legal abortion, which followed the
reform of restrictive state abortion laws in the late 1960s and the 1973
Supreme Court decision, was the most important factor in the large decreases
in neonatal mortality that occurred between 1964 and 1977."

The article then stated that "the neonatal death rate (the number of deaths in
the first 27 days of life per 1,000 live births) fell by 75 among white and by 11.8
among blacks." It also explained that neonatal mortality during the 1964-1971
period was "fueled by the increase in the percentage of low-income women
who used subsidized planning services between 1965 and 1971 and by the
dramatic increase in th<> legal abortion rate between 1969 and 1971 (emphasis
added). The acceleration of this (trend] — during the 1971-1977 period was due
to the ... explosion of the abortion rate during that period."

17. In July 21, 1993 the New York Times ran an article entitled "The Chosen Sex-a
Special Report". In it, the Times reports on a growing problem in China concerning
sex-selection abortions. The article speaks of how women go into clinics and
through the use of ultrasound, determine the sex of their child. Approximately 12%
or 1.7 million fetuses are being aborted every year in China, simply because the child
happens to be the wrong sex, a female.

Since you have on occasion stated that you oppose restricting a woman's access to
abortion for reasons other than "medical necessity" would you support a woman's
right to terminate her pregnancy simply because the child was the wrong sex? Do
you consider this a legitimate form of family planning?

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I support the principles set forth in Roe v. Wade concerning a woman's right
to choose.

I have never considered abortion as a means of family planning. To me, an
abortion is a failure in our system to provide women with sufficient tools to
control their reproductive cycles. I believe in preventing unplanned
pregnancies, therefore, eradicating the need for abortion.

ADDRESS TO ARKANSAS COALITION FOR CHOICE

1. Did you address the Arkansas Coalition for Choice on January 18, 1992? If so, did
you do so as Director of the Arkansas Health Department?

A: Yes, I did address the Arkansas Coalition for Choice on Saturday,
January 18, 1992. 1 did not do so in my capacity as Director of the
Arkansas Department of Health.

2. Have any complaints been filed against you for violation of Arkansas laws which
prohibit such actions by state officials? If so, what was your response?

A: On February 17, 1992 Westark Christian Action Council filed a written
complaint alleging that I had addressed the Arkansas Coalition for
Choice in my capacity as director of the Arkansas Health Department,
and therefore violated the Arkansas State Political .Practices Act On
March 13, 1992 County Prosecutor Mark Stodola completed an
investigation of the matter and announced that there had been no
violation of state law. On March 17, 1992 the Westark Christian Action
Council filed a petition in the Circuit Court of Pulaski County seeking
the appointment of a special prosecutor to investigate the
circumstances of the January 18, 1992 address. On May 26, 1992, upon
joint motion of both petitioner, Westark Christian Action Council and
myself, I was dismissed as a party to the proceeding. The request for a
special prosecutor was dismissed by the Circuit Court of Pulaski
County. Petitioners appealed to the Supreme Court of Arkansas, but
the appeal was dismissed because the case was moot

3. In responding to any suits alleging that you violated Arkansas law by addressing
the Arkansas Coalition for Choice on January 18, 1992, did you use attorneys paid for
by the state of Arkansas to defend you?

A: Yes, because I was served in a civil action alleging that I had acted

improperly under color of my office I did use the services of attorneys
employed by the Arkansas Department of Health in responding to the
action initiated on March 17, 1992.

4. What is the status of any suit pending against you alleging you violated Arkansas
law for speaking to the Arkansas Coalition for Choice on January 18, 1992?

A: On April 19, 1993 Westark Christian Action Council filed a second
petition in Pulaski County Circuit Court seeking appointment of a
special prosecutor. The second petition was substantially similar to the
petition that was dismissed in 1992. It is my understanding that no
parties have been served in this action, and I have no personal
knowledge of the status of this proceeding.

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5. Have petitions been filed requesting the appointment of a special prosecutor to
bring suit against you for alleged violations of Arkansas law because of your address
to the Arkansas Coalition for Choice? If so, what is the status of this request?

A: On March 17, 1992 the Westark Christian Action Council, filed a

petition seeking die appointment of a special prosecutor to investigate
the circumstances of the January 18, 1992 address. On May 26, 1992,
upon joint motion of both petitioner, Westark Christian Action
Council and myself, I was dismissed as a party to the proceeding. The
request for a special prosecutor was dismissed by the Circuit Court of
Pulaski County. Petitioners appealed to the Supreme Court of
Arkansas, but the appeal was dismissed because the case was moot

On April 19, 1993 Westark Christian Action Council filed a second
petition in Pulaski County Circuit Court seeking appointment of a
special prosecutor which was similar to the petition that was dismissed
in 1992. It is my understanding mat no parties have been served in mis
action, and I have no personal knowledge of the status of this
proceeding.

6. During your address to the Arkansas Coalition for Choice on January 18, 1992, did
you make the following statement

".... and there the Church was silent when we talked about... the first 400 years black
people had their freedom aborted, and the Church said nothing. The way of life for
Native American was aborted; the Church was silent We attempted to eradicated a
whole race of people through the Holocaust, and the Church was silent.... Women
had no right to vote for years. We ask why? Why do these things go on?... Any time
the right of choice is taken away from all of us and put into the hands of a few, these
kinds of things will happen, over and over again. Look at who's fighting the pro-
choice movement a celibate, male dominated church...."

A: Yes.

7. Were you ever asked to publicly apologize for the above statement? If so, did you
publicly apologize? When and where?

A: Yes, I was asked to apologize by a priest I discussed this with Bishop
Andrew McDonald and my brother (who is a minister). I explained
mat I did not have any preconceived malice or intent to blaspheme the
Roman Catholic Church. It was agreed that in the future I would refer
to the church as "male-governed" rather than "male-dominated." I
later sent a letter of apology to Bishop McDonald to that effect

CONDOM ADVERTISEMENTS

1. Do you support advertising condoms on television?

When asked if as Surgeon General you would target networks for their continued
refusal to air condom ads, you responded, "I most certainly wilL You know, I feel
we air everything else and I feel that the media - I feel that the media can make
very, very significant impact on the attitudes of America." The Reuter Transcript
Rept December 30, 1992

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A: I do support advertising condoms on television. I believe if we advertise
feminine napkins and douches, we can also tastefully advertise condoms.
We need to make condoms an every day item of personal hygiene for people
who choose to be sexually active outside of a monogamous relationship.
Otherwise, we are never going to successfully fight the spread of AIDS.

During my time in Arkansas, one of the television stations devoted all of its
public services announcements to the issue of teen pregnancy. Its campaign
was very tastefully done and had a major impact on the public perception of
this issue The station received a Regional Emmy Award, the George Peabody
Award and the Edward R Murrow Award for their work.

We are not doing a very good job at promoting condoms. If confirmed, I will
work to increase the acceptability of condoms among all populations within
our country by using every tool available, including the media. I feel very
strong about this.

CONTRACEPTIVES

1. You have had a lot to say about condoms. Given the fact that condoms have been
promoted, distributed and made available more in the last several years than in
their entire history, why is it that sexually transmitted diseases, teen pregnancies,
and AIDS continue to increase?

A: Yes, adolescent pregnancies, sexually transmitted diseases, and AIDS continue
to be problems. And yes, condoms are promoted, distributed and made
available more than ever. However, 1) condoms are not used by all couples, 2)
condoms are not used properly or consistently by all couples, and 3) condoms
can be defective or break. No form of contraception is 100% effective except
abstinence, and I do support abstinence, especially for adolescents. However,
for those persons who choose to be sexually active, I have advocated the use
of condoms in promoting "safer sex."

Z Grady and Cowarker report that condoms have an 18% failure rate for pregnancy
among teenagers (and this doesn't even count all the pregnancies that were
aborted). This means that when the failure rate is that bad, one in five girls who
depend on condoms ends up pregnant An editorial appearing in Postgraduate
Medicine, written by its editor-in-chief. Glen C Griffin, MD states. The only really
safe sex is between two faithful marriage partners who are free of sexually
transmitted diseases." Dr Griffin says kids need to know that "this no-risk sex is
worth waiting for." Do you agree with his statement? If so, how will you promote
truly "safe sex" as surgeon general?

A: I agree that "no-risk sex is worth waiting for." However, I believe in facing
facts, and the reality is that some persons choose to have sex in other than
mutually monogamous relationships. For those persons, I would offer the
same advice as my predecessor, Dr. Koop. That is, in the absence of such a
relationship, both parties should protect themselves and use condoms.

3. Is the transmission of Chlamydia infection prevented by condoms? What is the
rate of Chlamydia infection among teenagers? What are the consequences of a
Chlamydia infection for a teenager?

A: The transmission of Chlamydia trachomatis infection is prevented by latex
condoms used correctly and consistently. Judson, et. al. found no leakage

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when 50 unlubricated standard latex condoms with a receptacle "end with 10
ml pooled suspensions of Chlamydia Trachomatis were subjected to vigorous
simulated "intercourse" in an in vitro setting. (Condoms in the Prevention Of
Sexually Transmitted Diseases. American Social Health Association,
December 1989.) The CDC, Division of Sexually Transmitted Disease and HTV
Prevention concurs that latex condoms prevent transmission of Chlamydia
trachomatis.

The rate of Chlamydia trachomatis infection is 10-15 percent nationwide.
Data is not recorded nationally in an age specific manner.

Infection with Chlamydia trachomatis can result in pelvic inflammatory
disease (PTD), sterility, ectopic pregnancy, and neonatal pneumonia.

4. What is the human papilloma virus and its associated consequences? Is this
transmission of human papilloma virus prevented by condoms? What percent of
sexually active teens carry this virus? Is it curable?

A: There are many types of the human papilloma virus (HPV). Types 6 and 11
are associated with what is commonly known as genital warts, which may be
permanently removed in an office setting. HPV types 16 and 18 have been
associated with cervical dysplasia and malignancies. There are many
procedures and treatments for cervical dysplasia and early stages of
malignancies which attain cure. Transmission of HPV is prevented by
condoms, according to the Division of STD/HTV Prevention, CDCP. Ten to
fifteen percent of sexually active teens carry HPV.

DEFECTIVE CONDOMS

1. According to documents obtained from the FDA, the Arkansas Department of
Health had repeated problems with condoms that it was obtaining from its sole
supplier, Ansell, Inc. When did your agency begin purchasing condoms from
Ansell?

A. The relevant Arkansas Department of Health records are not available prior
to 1988, by which time the Department was purchasing condoms from Ansell.
I believe that the Department had been purchasing Ansell condoms for
several years before 1988.

2. Did any problem with the condoms surface before December 1990?

A. I know of no reported or documented complaint about the Ansell
condoms at the Arkansas Department of Health prior to December,
1990.

3. In December 1990, a high school clinic in your state returned 50 condoms to your
department These condoms had been supplied to the school by your health
department and were returned by the school because of complaints of breakage. An
official with your agency sent the condoms back to the manufacturer. What efforts
did your department make to notify high school children who had received
condoms from that batch of the problems that had been detected? Were the
students asked to return the condoms to the school-based clinic and receive
replacements? If not, why was the decision taken to let students use condoms from
a batch that the clinic believed had unacceptably high levels of defects?

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A. The Arkansas Department of Health began distributing Ansell
condoms years before December, 1990. The product typically was
distributed with 3 packages to a unit 48 units to a box, 10 boxes to a case.
Each case, then, contained approximately 1044 condoms. The first
reported complaint to the Arkansas Department of Health occurred in
December, 1990. The Department of Health returned 50 condoms to
Ansell due to a high school clinic's complaint to the Department about
"breakage". That clinic's communication to the Department was based
on one student's report of his experience. The number of condoms
distributed at that clinic and the number of those which were not
defective does not appear in the records of the Arkansas Department of
Health. When notified of the student's experience, Ansell replied that
the condoms had been manufactured to meet product specifications
and had passed a quality control test prior to distribution Ansell
reported to the Department that no other complaints had been received
on these condoms. Therefore, in December, 1990, there was insufficient
basis on which to notify users that there had been a complaint about
breakage and/or that all users should return condoms to the school-
based clinic

4. Similar problems continued to be reported in clinics throughout your state.
Generally, your department handled these problems by exchanging one batch of
condoms for another made by the same manufacturer. Did your agency also notify
people who already had received the condoms about the potential hazards?

A. Between December, 1990 (when one clinic reported a breakage problem)
and February, 1992 (when a county health unit reported another), to
my knowledge, the Arkansas Department of Health received nfi reports
of breakage in the condoms it distributed. From February, 1992 until
Ansell instituted a nationwide recall of its product in September, 1992,
there was only one occasion (in addition to the instance prompted by
the December, 1990 communication) in which Ansell replaced the
condoms previously supplied to the Department of Health. The
replacement supply consisted of a different, stronger condom than the
ones previously purchased by the Department of Health. In February,
1992, there was insufficient basis on which to notify users not to use the
Ansell condom.

5. On June 24, 1992, the Baxter County Health Unit notified an official in your
department that "three successive HTV antibody test clients who were issued
Lifestyle condoms during their pre-test counseling stated that the condoms broke in
every use." This occurred at least 18 months after your department had been
informed of serious problems with condoms from this manufacturer. Did your
agency alert other clients who had been tested for HIV infection that the condoms
the clinic was distributing had high failure rates?

A. The December, 1990 report of "breakage" made no reference to or

finding of "serious problems with condoms from this manufacturer."
There were no reports to the Department about condom failure during
1991. During 1992, the Department of Health was seeking to collect the
experience in the State with Ansell condoms. That process was .

ongoing during June, and thus no notification of "high failure rates"
was indicated.

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6. Throughout much of 1991, the state legislature engaged in a rather contentious
debate over the question of whether school-based clinics should dispense condoms.
During this same period, your clinics were experiencing serious problems of
breakage and leakage with the condoms that it was distributing to the public Had
your agency made a conscientious effort to notify persons who had received
condoms from your clinics to this fact, what effect would this have had on the
legislature's deliberations?

A. During all of 1991, to my knowledge, the "Department of Health
received no reports of breakage or leakage in the use of Ansell
condoms distributed by the State. I do not know what the effect on the
legislative debate would have been had the Department experienced
serious problems with the condoms and reported that fact to the
Arkansas legislature.

7. Eventually, the FDA approved a seizure of every condom that your agency had
purchased from Ansell, Inc. The FDA never went through with the seizure, nor did
it order a recall Instead, it suggested that you return condoms still in your
inventory to the manufacturer. At this point, having returned all of your stock of
Ansell condoms to the manufacturer, did you instruct your state public health
clinics to notify people who already had received condoms of the possible defects?

A. On August 12, 1992, the Nashville office of the Food and Drug

Administration recommended a seizure of Ansell products. That
seizure would have affected only those products actually tested in
Arkansas and found defective Other Ansell products — those that had
not specifically been tested in Arkansas or elsewhere in the nation —
would not have been affected by a seizure. A recall, but not a seizure,
can reach product beyond that actually tested and found deficient

On August 28, 1992, the Center for Devices and Radiological Health
within FDA concurred with the Nashville FDA office's
recommendation for a seizure. On September 3, 1992, before the seizure
decision was finally endorsed and implemented, Ansell wrote to FDA
announcing that it would recall die product nationally. Customers in
twenty-seven states plus Guam and the District of Columbia were
contacted by the manufacturer and returned to Ansell their supplies of

the product The manufacturer destroyed the returned condoms on
April 8, 1993.

To my knowledge, Arkansas was the only Department of Health that
brought to FDA's attention its experience with Ansell condoms.

Meanwhile, on July 21, 1992, the Department of Health wrote to all
Area Managers of the Department regarding the Ansell condoms.
Among the instructions to the Managers was the following: "1.
Review with the client the reasons for condom breakage .... Most
breakage problems can be solved with a review of proper handling and
use. 2. If no explanation is evident have the client return any unused
condoms and send them to the Department of Health for testing."

8. Did your agency, at any time during the 19-month period of time during which
you experienced repeated problems with condoms purchased from Ansell, make
any effort to notify people who had obtained condoms from your clinics, including
school-based clinics, of these problems? Did your agency undertake any program to
ask people who had been given these condoms that they should return them to
your clinics and exchange them for more reliable condoms?

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A. As noted earlier, there was not a period of 19 months in which the

Department of Health "experienced repeated problems with condoms
purchased from Ansell...". As also noted earlier, in July, 1992, the
Department notified all Area Managers to "...have the client return
any unused condoms".

9. Throughout much of 1991, the Arkansas legislature debated whether to continue
the Health Department's program of dispensing contraceptives to high school
students. Did you at any time notify lawmakers that your agency was distributing
defective condoms to high school students under this program?

A. I did not notify lawmakers in 1991 about the condoms the Department
of Health was distributing. As noted earlier, to my knowledge, the
Department had no reports of breakage or leakage involving Ansell
condoms during all of 1991.

10. Did you at any time notify the Governor of the fact that your clinics were
dispensing defective condoms? If so, when? What steps, if any, did he direct you to

take to ensure the safety of people who had received condoms from your clinics?
Did he direct you to notify people who had received condoms from your clinics to
return them in exchange for more reliable condoms?

A. I did not notify the Governor when I received reports about condoms
from local or area health units. I did not notify the Governor that
there were no reported problems with the Ansell condoms during
1991. The Governor did not, then, give me directions regarding the
distribution of condoms.

FAMILY PLANNING

1. It was recently announced that Baltimore City Schools are expected to be the first
in the nation to offer Norplant, a surgically implanted contraceptive, to teenage
girls. The drug is expected to be offered to students at Laurence Paquin Middle and
High School, and will eventually be expanded to the six high schools that have
school-based health clinics on campus.

a. Do you support the distribution of Norplant to this population?

A: Norplant, a new implantable hormonal, long-term contraceptive, has been
approved by the Food and Drug Administration as safe for use as a
contraceptive method in the United States. Local community groups have a
right to provide voluntary contraceptive services to sexually active
individuals in compliance with any relevant Federal, State or local
requirements, including informed consent requirements.

b. Given the drug's short history, do you believe these minor girls should have to
obtain parental consent before implanted with Norplant?

A: Norplant has been approved by the FDA as a safe, reversible family planning
method. These inserts can be removed through a simple, outpatient
procedure. As with all other contraceptive services provided to adolescents
through the Title X national family planning program, Norplant is available
to adolescents who request such services on a confidential basis. I would
however urge parents to become involved with their children's decisions
whenever practicable.

154

c If you do not support parental consent before Norplant is distributed to minor
girls/do you at least support parental notification before this new drug is

distributed?

A: There are no Federal laws that require parental consent or notification for the
provision of contraceptive services to minors, nor would I recommend that
Norplant be singled out for such a requirement

d. Would you support using federal funds for this type of distribution?

A: Funding for the provision of Norplant is currendy available through various
Federal programs including Medicaid and the Title X national family
planning program. Title X specifically requires that all family planning
services to adolescents be provided in a confidential manner, and prohibits
parental consent or notification requirements for the provision of such
services.

e. What if any restrictions would you place before federal funds could be used to
distribute Norplant to minors?

(see above response)

2. Section 1008 of the Public Health Service Act implementing the title X Family
Planning Act provides that "None of the funds appropriated under this Title shall
be used in programs were abortion is a method family planning."

a. How do you interpret this section of the law, which has not been altered since
1970?

A: The Tide X statute has always prohibited the use of funds for abortion. The
Department of Health and Human Services is not seeking any change in that
prohibition.

b. Do you support regulations know as the "Gag rule" which aim to separate
abortion related activities from federally supported family planning activities. If
not, do you support any limitation on the ability of clinics receiving federal funds to
counsel or refer women for abortion in federally funded Tide X clinics?

A: I support the President's position as expressed in his January 22
Memorandum in which he directed the Department to suspend the so-called
"eae rule" and promulgate new regulations to implement Section 10O8 in
accordance with the notice and comment procedures of the Administrative
Procedures Act

Under suspension of the "gag rule". Title X family planning projects must
provide information on all pregnancy options for managing an unintended
pregnancy when asked by a client

c Do you view the federal family planning program as preventive in nature?

A- Yes family planning is our best means of planning pregnancies and avoiding
the need for abortion, and I support making family planning services more
accessible.

155

d. Do you think it is important to separate abortion activities from legitimate family
planning or preventive activities? How do you propose to separate abortion
activities from legitimate family planning activities?

A: Under suspension of the "gag rule", grantees must comply with section 1008,
with the "Title X guidelines, and with the program policies developed since
the inception of the program that were jn effect prior to 1988 dealing with the
interpretation of the abortion restrictions in Tide X A statement published
by the Department in the Federal Register on June 23, 1993 announced the
availability of a summary of pre-1988 policies. This summary outlines the
standards to be applied to insure sufficient separation of abortion activities
from Title X activities.

e Should Title X clinics be permitted to perform abortion on the same site as the
federally funded Title X clinics?

A: Under suspension of the "gag rule", the title X program is operating under
program policies that were in effect prior to 1988 which require that projects
maintain some degree of separation from abortion activities. A statement
published by the Department in the Federal Register on June 23, 1993
announced the availability of a summary of pre-1988 policies. This policy
summary states, "separation of Title X from abortion activities does not
require separate grantees or even a separate health facility, but separate
bookkeeping entries alone will not satisfy the spirit of the law." I believe this
is a reasonable approach but I would like to reserve my final opinion until

the comment period has closed and comments on this and other policy
positions are analyzed.

f. Should personnel whose salaries are supported by federal funding be permitted to
work in abortion related activities at the same site?

A: Under suspension of the "gag rule", the title X program is operating under
program policies that were in effect prior to 1988 which require that projects
maintain some degree of separation from abortion activities. A statement of
those policies which was published by the Department in the Federal Register
on June 23, 1993 announced the availability of a summary pre-1988 policies.
This policy summary states, "Similarly, common staff is permissible, so long
as salaries are properly allocated and all abortion-relation activities of staff
members are performed in a program which is entirely separate from the
Title X project I believe this is a reasonable policy but I would like to reserve
my final opinion until the regulation comment period has closed and
comments on this and other policy positions have been analyzed.

3. Since its involvement in funding contraceptives and family planning, the Federal
government has invested over $2 billion to curb teenage pregnancy. Yet the rate of
teenage pregnancy and sexually transmitted diseases afflicting teens continues to
grow.

Many experts feel it is time for us to admit that this approach has not yielded the
returns we had hoped for, and to recognize that we have focused on the symptom of
teen pregnancy rather than the root, which is teen sexual activity.

a. What, if anything, will you direct the Department of Health and Human Services
to do to curb the rate of teen sexual activity?

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b. What role should abstinence education play in this effort?

A: Abstinence education, including teaching resistance and decisionmaking
skills, is obviously an important part of any sexuality education program,
especially when targeting younger adolescents. I would expect such a
component to be included in comprehensive school health education
programs. _

MARIJUANA

1. Do you, as the press has reported, support a physician's right to prescribe
marijuana for their patients, if it would be "beneficial"?
(The Salisbury Post, December 20, 1992)

A. If the Department of Health and Human Services concludes that the
use of marijuana for therapeutic purposes is beneficial. Research is
currendy being performed as to the therapeutic benefits of marijuana
for such diseases as glaucoma, cancer, and AIDS. I believe the Secretary
is planning to review the issue of marijuana's use for those purposes. I
support such a review and would, therefore, defer a conclusive
statement on the matter until the review has been completed.

2. Are you aware that Federal drug agencies prohibit marihuana's medical use
because smoking it may cause lung cancer, may damage brain cells and compromise
the immune and reproductive systems?

A. I am aware of the health risks associated with marijuana.

3. Would you use your office as Surgeon General to promote marijuana's
"medicinal uses"?

A. Again, I would await the results of the Secretary's planned review
before reaching any conclusions on the matter.

MERCY NURSING HOME
1. Did the Mercy Nursing Home provide home health services?

A: No.

2. Was Audrey Ruffin ever employed or connected with the Mercy Nursing Home?
Is so, would her health care have been regulated in any way by the Arkansas
Department of Health?

A: Ms. Ruffin at one time was employed by the Mercy Nursing Home. Her
health care was not regulated in any way be the ADH

157

3. Could you please explain the Arkansas Department of Health's involvement in
the provision of home health services?

A: The ADH provides home health care services in all but six counties in

Arkansas. These services include providing nurses, nurses aids and licensed
practical nurses to assist in the patient's home as ordered by the attending
physician.

4. Please explain how the ADH operates its home health agency.

A: ADH operates its home health agency under a certificate of need for each
county in which it provides services. Payments must be approved by
Medicare, as they must be for any other home health agency.

5. When did you first become employed by the Mercy Nursing Home?

A: I first became employed by the Mercy Nursing Home in or about 1959, while I
was still a medical student

6. What was your position at the Mercy Nursing Home? Please describe your
responsibilities and activities at the nursing home

A: When I was first employed at the Mercy Nursing Home, I worked under the
supervision of a licensed doctor to provide any needed medical care to the
residents. In or about the late 1960s, I became the Medical Director of the
nursing home. In that capacity, I oversaw the medical procedures at the
nursing home, referred patients as needed to outside physicians for medical
care, and otherwise supervised the medical needs of die residents.

7. As Director of the Arkansas Department of Health (ADH), did you play any
regulatory role with respect to nursing homes?

A: The ADH does not play any regulatory role with respect to nursing homes.

8. What financial responsibilities did you have in relation to nursing homes as
Director the ADH?

A: As Director of ADH, I had no financial responsibilities in relation to nursing
homes. See response to Question 7 above.

9. What state or federal assistance would the Mercy Nursing Home have received?

A: The Mercy Nursing Home would have received Medicare and Medicaid
payments, as do most nursing homes in the state.

10. According to a letter from the ADH dated April 18, 1989, (Appendix A), the
ADH's home health agency operates on "'reimbursements from Medicare and
Medicaid," among other public funds. Do you see any conflict of interest in
receiving a salary from a nursing home, while simultaneously serving as the
Director of the ADH?

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A- I saw no conflict of interest whatsoever in receiving a salary from a nursing
home while simultaneously serving as the Director of ADH. As noted in
response to question 7, ADH did not regulate nursing homes. The fact that
ADH has a home-health agency that operates on "reimbursements from
Medicare and Medicaid" did not in my judgment create a conflict of interest

11 During testimony before the Committee, you indicated that you served
simultaneously as Director of the ADH and as the medical director of the Mercy
Nursing Home for "-nine months or so." You stated that the nursing home closed
only "...months after (you) became health director". You became Director of the
ADH in October 1987, yet your 1989 financial disclosure indicates you were still being
paid by the Mercy Nursing home in 1989. Did you hold both of these positions
simultaneously for only nine months? Please clarify.

A: I do not have any record of precisely when I ceased working as the Medical

Director of the Mercy Nursing Home. As best I now recall I ceased working at
the Mercy Nursing Home in or about November 1989 or until all patients
requiring nursing home care were transferred to other facilities. The
disclosure form filed in 1989 listed my salary for the 1988 calendar year. The
form that would have been filed in 1990 would have reflected the Mercy
Nursing Home income received in calendar year 1989.

At the time of the hearing, I was under the impression that the nursing home
had closed in 1988. Upon reflection, I believed that the nursing home may
have dosed in 1989.

12. Were there any contractual agreements between the State of Arkansas and Mercy
Nursing Home?

A: I have no knowledge of any contractual agreements between the State of
Arkansas and Mercy Nursing Home. The Mercy Nursing Home had a
certificate of need issued by the state of Arkansas.

13. As Director of the ADH, did you ever file any recusals with respect to Mercy
Nursing Home?

A: I do not recall any issues that related in any fashion to the Mercy Nursing
Home coming before me as Director of the ADH. As a result, I have no
recollection of ever filing a recusal with respect to the Mercy Nursing Home.

14. Was Audrey Ruffin ever an employee of the Mercy Nursing Home? If so, was
this at the time that she was employed to care for Leona Elders?

A: As I stated in response to Question 2, Ms. Ruffin was at one time an employee
of the Mercy Nursing Home I do not recall whether she may have continued
to work there on a part time basis after she was hired by my father-in-law to
care for Mrs. Elders in the summer of 1988.

15. According to the Associated Press, Mercy Nursing Home's 85 beds were assigned
to another facility. What facility was the Mercy Nursing Home assigned to? What
role, if any, did the ADH have in this assignment?

A: The Mercy Nursing Home sold its certificate of need to another facility. ADH
had no role in this sale.

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NATIONAL BANK OF ARKANSAS

1. You testified on Friday that you had been reprimanded by the Comptroller of the
Currency as a director of the National Bank of Arkansas ("NBA"). You further
testified that the Comptroller of the Currency found that you and your fellow
directors did not, in the opinion of bank examiners, take adequate action to correct
the activities of bank management that had previously been cited. What unsafe and
unsound banking activities was the management cited for?

A: Management of the NBA was cited by the Comptroller of the Currency for
loans in excess of lending limits, inaccurate call reports, improper
investments, improper loans to an affiliate, and excessive investment in bank
premises.

2. Did these involve loans to a Little Rock business man named James R Hodges?
A: Yes.

3. Did you know Mr. Hodges? If so, what was your relationship to him?
A: I did not know Mr. Hodges.

4. At what point did you become aware that the National Bank of Arkansas had
extended loans totaling $2.82 million to Mr. Hodges over a period of five years?

A: I became aware through briefings on the examination report that the OCC was
taking the position that the National Bank of Arkansas had extended loans
exceeding the lending limit to Mr. Hodges and his affiliated companies. I was
not aware at the time the National Bank of Arkansas extended the loans to
the various entities that they were affiliated with Mr. Hodges. As a result, I
was not aware that the NBA was exceeding the loan limit According to
Ronald Tulles, then President of NBA, the loan officer failed to disclose to
bank management and the Board of Directors that the entities were affiliated.

5. Were you present at any board meetings during which the loans to Mr. Hodges
were discussed?

A: After the OCC examination report, I was present at several board meetings
where the board discussed methods of bringing the Hodges-related loans into
compliance with the lending limit.

6. Did you vote with other directors to approve a loan to a Mr. Dan Walker of First
American Savings Association of Benton, Illinois?

A: I have no specific recollection of voting with the other directors to approve a
loan to a Mr. Dan Walker of First American Savings Association of Benton,
Illinois. I may have done so.

7..Were you aware of a commitment from Mr. Walker to guarantee a loan to Mr.
Hodges that would permit Mr. Hodges to repay the National Bank of Arkansas?

A: If there was such a commitment, I was unaware of it

160

8. Did you agree with other directors to approve this illegal transfer of funds? If
not, did you vote or otherwise express your opposition to this illegal activity?

A: I was not aware that the loan to Mr. Walker was improper in any fashion, and
to my knowledge none of the other directors believed that the loan to Mr.
Walker was improper or unlawful. Since I was unaware that the loan was
improper, I did not express my opposition to the loan. Had I known that the
loan was improper, I would have opposed approval of the loan.

9. What other safety and soundness violations was management cited for?
A: See response to Question 1 above

10. What corrective actions were called for by Comptroller of the Currency?

A: As I recall from the briefings at board meetings around the time of the

issuance of the OCC examination report, the OCC called for tighter procedures
to ensure that the NBA did not engage in investments exceeding the loan
limit, to prevent the filing of inaccurate call reports, to monitor closely all
investments, to prevent improper loans to an affiliate, and to preclude excess
investment in bank premises.

11. Which corrective actions were taken, in the judgment of the banking examiners?

A: I believe that the banking examiners acknowledged that the bank had taken
some corrective measures including adoption of policies to minimize the
likelihood of future violations of the lending limits.

12. Which were not taken?

A: I believe that the bank examiners took the position that the bank had not

taken sufficient steps to obtain repayment of the Hodges-related loans. Bank
examiners also believed that the bank had taken insufficient steps to collect
on a loan involving an affiliate. As to a number of the other alleged issues,
the bank examiners acknowledged that they were not brought to the attention
of the bank until after I was no longer a director.

13. You also testified on Friday that you and other directors had voted yourselves an
unsecured $230,000 line of credit You said that you abstained on the vote to extend
you that same line of credit Was this a "round robin" vote — in other words, did
you abstain from voting on your own line of credit while voting to establish such a
line of credit for others, and did other directors do the same?

A: I did not testify that the directors of the bank voted themselves "an unsecured
$230,000 line of credit." To the contrary, I testified that I believed that the
"line of credit" represented a lending -limit and was not in and of itself an
extension of credit on which I could draw. As I testified, all loans that I
thereafter obtained from the NBA were individually approved as required
and at rates and terms generally available to other borrowers. As I recall, the
votes of the Board of Directors to establish these lending limits occurred
during one meeting in 1981 and one meeting in 1982. On each occasion, I
abstained from voting with regard to my "line of credit" limit

161

14. At the hearing, you were asked whether you recused yourself "from discussion
or approval by the board of any loan that you had requested." Your answer was that
you had abstained from the vote giving you a $230,000 unsecured line of credit. Did
you also recuse yourself from discussion or approval by the board of other loans that
you had requested from the NBA?

A: I do not recall whether the particular loans that I sought from the NBA were
individually approved by the board ancfwhether I attended the meetings if
such approval occurred. At such a meeting, I would have recused myself
from discussion or approval by the board of such loans to myself.

15. Are you able to serve as a director of a financial institution without obtaining
clearance from federal banking regulators?

A: I believe that the federal banking regulators approve directors of a federally
chartered financial institution. There was no other restrictions on my ability
to serve as a director as a financial institution.

16. In your position as a director of the board of the Arkansas National Bank, did
you violate federal law? Did you violate the National Banking Act?

A: As I testified at the hearing, I was briefed at board meetings on the content of
examination reports by the OCC and the president of the board. I was advised
that all directors were cited in the examination report as having violated
national banking laws and safety and soundness laws relating to their failure
to supervise bank management I was advised that the examination report
did not find their activities to be criminal.

NORPLANT FOR PROSTITUTES

1. During a phone in program called Talk Live, you were asked what you would do
with crack addicted prostitutes who get pregnant You responded, T would hope
that we would provide them Norplant so they could still use sex if they must to buy
their drugs and not have unplanned babies." Would you recommend we use
federal funds for this purpose?

A: I would, of course, strongly urge women not to use crack or engage in
prostitution. Those women who do engage in prostitution should use barrier
methods to protect themselves and their partners from disease. I also would
encourage use of a highly effective contraceptive method like Norplant to
prevent unwanted pregnancies. The FDA has approved of the use of
Norplant as a contraceptive and Norplant is included as a covered device by
Medicaid in all 50 States. As with any contraceptive, Norplant is only
provided to women who give their informed consent for the procedure.

Certainly, Norplant is only distributed with informed, written patient
consent.

162

2. Are you at all concerned about linkages between drug abuse, prostitution and the
spread of AIDS?

A: Yes. Drug abuse and prostitution are among the causes for a rising rate of
HTV infection among women. We need primary prevention to help women
avoid drug abuse and we need more intervention and access to
comprehensive services for women who desire to stop their drug addiction or
prostitution- Currently, we have many more women asking for these services
than we have spaces available

PAY ISSUE

1. A series of opinions prepared by the Office of the Attorney General for the State of
Arkansas indicate that you had a special arrangement to receive a salary in excess of
the cap mat applied to all other state employees, including the Governor. Under
this arrangement, the Department of Health, which you headed, transferred the
amount of your salary (and, at least in some years, additional funds as well) to the
University of Arkansas Medical School. UAMS then added more money to the sum
that had been transferred from the Health Department and paid you as a faculty
member. When did this unique salary arrangement begin?

A: I believe that the salary arrangement began in fiscal year 1987-88. I do not
believe that the arrangement is unique Several other states, including
Florida, Texas, and Washington, D.C have similar arrangements to
encourage medical professionals to accept supervisory positions in their
respective departments of health.

2. Did the Attorney General approve this arrangement? If so, for which years was
approval given? For which years was approval "not obtained?

A: It is my understanding that the Attorney General was not asked to approve
the method by which I was compensated. My understanding is that the
Arkansas Department of Finance and Administration approved the contract
each year.

3. Did the Chief Fiscal Officer of the state approve this arrangement? If so, for which
years was approval given? For which years was approval not obtained?

A: Yes. The Department of Finance and Administration, which is headed by the
Chief Financial Officer, approved this arrangement in each year.

4. With whom did you negotiate this arrangement? Was the Governor involved in
these discussions?

A: I did not negotiate the contract, which was between the University of

Arkansas Medical School ("UAMS") and the Arkansas Department of Health.
The Governor initially offered me the position, but I informed the Governor
that I could not accept the position if it required me to resign from my
tenured faculty position with UAMS and to take a reduction in salary. I do
not know whether or to what extent the Governor was involved in the
discussions between UAMS and the ADH.

163

5. An April 7, 1988 Attorney General opinion stated: "An employee of a state agency
who is drawing the maximum salary with that agency would presumably be
drawing in excess of that maximum upon receipt of any salary or stipend received by
virtue of a contract or employment with another state agency.'" Prior to the issuance
of this opinion, did you receive any salary or stipend from UAMS in excess of the
maximum salary set by the state legislature for the Director of the State's
Department of Health? _

A: My salary was approved by the appropriate state authorities and it is my
understanding it did not violate applicable state law.

6. Did you receive any salary or stipend from UAMS in excess of the maximum
salary set by the state legislature for the Director of the state's Department of Health
subsequent to the issuance of the April 7, 1988 Attorney General's opinion?

A: See answer to Question 5 above.

7. An Attorney General opinion dated July 11, 1990 described your pay arrangement
as follows:

"The Department of Health takes the $72,907 appropriation for the director's [i.e., the
Director of Health] salary and pursuant to A.C.A. 19-4-526, has it transferred to a
budget classification for professional services contracts, and then pays the salary,
plus an additional $14717 from unidentified sources, to UAMS, which uses it to
help pay Dr. Elders's UAMS salary. Thus, this sum is paid by the Department of
Health to UAMS, and then paid by UAMS to Dr. Elders as a part of the total
compensation she receives from UAMS."

Since you were Director of the Department of Health, can you please describe how
this transfer of funds from the agency you directed to UAMS was accomplished?

A: It is my understanding that the Department of Health forwarded each month
one-twelfth of my annual salary as the Director of Health to UAMS. There, it
is my understanding that the payment was commingled with funds UAMS
receives from all other sources.

8. Can you also explain where the $14717 of additional Health Department funds
came from? Were they taken from a state health program? Were they taken from
state personnel funds? If not, where did this money come from?

A: It is my understanding that the additional funds came from the Department's
general operations budget, derived from its state appropriation.

9. Did the Chief Financial Officer and relevant agency heads certify that the
performance of your work as Director of tine Department of Health would not
interfere with your duties as a faculty member at UAMS

A: No. The Department of Health and UAMS jointly made that determination.

10. What were your duties as a faculty member of UAMS during your tenure as
Director of the State Department of Health?

164

A: I performed occasional services such as publishing scholarly articles, taking
medical students on rounds, and lecturing at UAMS seminars. I also served
on the Human Research Advisory Committee and was a member of the
faculty in the division of Pediatric Endocrinology and performed duties such
as clinics rounds and consultations with faculty, students and housestaff.
11. Did your "personal services contract" for years after 1991 provide for you to
receive additional compensation beyond the amount that you were entitled to
receive in your capacity as Director of the Department of Health?

A: I did not have a "personal services contract" The contract was between
UAMS and the Department of Health.

12. Were you also paid by the Arkansas Children's Hospital at any point in your
tenure as Health Director? If so, how much were you paid, and during what time
period did you draw this pay? What conflicts of interest did this create since, as
Health Director, you had certain administrative responsibilities for the hospital?

A: I was a member of the University of Arkansas School of Medicine faculty

which provided professional services to Arkansas Children's Hospital. I had
an appointment at Arkansas Children's Hospital as a Professor of Pediatric
Endocrinology. I did not receive a separate salary from the Arkansas
Children's Hospital. As a result, I saw no conflicts of interest in my role there.

13. What discussions have you engaged in with officials of the US. Department of
Health and Human Services or any officials of the United States government to
allow you to draw a salary in addition to the salary appropriated by Congress for the
Surgeon General of the United States?

A: I have had no discussions with officials of the VS. Department of Health and
Human Services or any officials of the United States government concerning
allowing me to draw a salary in addition to the salary appropriated by
Congress for the Surgeon General of the United States.

SEX EDUCATION

1. Is it true that you believe sex education should begin in kindergarten? (Arkansas
Gazette, July 3, 1988). You are quoted as saying "We taught them what to do in the
front seat. Now it's time to teach them what to do in the back seat" (Evening
Times, West Memphis, Ark.)

A: I have never said "sex education" should begin in kindergarten. I believe in
age-appropriate, comprehensive health education in grades K - 12. I have
made the statement concerning the front seat /back seat All schools in

America teach driver's education because we recognize the importance of
providing our children with the skills necessary to negotiate on our freeways.
We teach them not to drink and drive, to wear seat belts and to obey traffic
regulations. I was just reflecting on my belief that we need to also recognize
the need to provide our children with adequate tools to negotiate life's
highways- Hopefully, that means the ability to say "no" to sex, until they are
married. We would all want this for our children. However, if they do not
adopt that value, then I would hope that we could at least teach them to be
responsible so they do not bring another life into this world until they are
ready to accept the overwhelming responsibility that childrearing brings to
parents today.

165

2. What do you mean by sex ed in kindergarten? Are you familiar with any of the
literature developed for students by Marcia Quackenbush? One of the books "A
Kid's First Book About Sex" is described by the author as an introduction to sexuality
for young readers. The table of contents reveals chapters on "Your Body, Nudity,
Touching, What is Sexy, Sex Parts, Feeling Sexy (Orgasm), Masturbation, Sexual
Intercourse, etc..) Are these the types of subjects you think should be discussed with
pre-schoolers?

A: I have never used the term "sex ed" for kindergarten students. I believe in
comprehensive age-appropriate health education. That means teaching
children the "need to know" information concerning their health, their
bodies and themselves. For very young children, that means teaching them
that there are places on their bodies that nobody should touch and if someone
does, they should go tell somebody about it It means teaching them about
nutrition, personal hygiene, the health consequences of tobacco use, alcohol
abuse and drug abuse. We need to teach health education like we teach math,
every day in our classrooms. Instead, too many of our programs only offer a
thirty minute lecture once a month or so. This strategy will not effectuate
behavioral change in our young people. Good health must become a way of
life To do this, yes, we must start early.

I am not familiar with Ms. Quackenbush's work.

SOCIAL SECURITY AND FICA

1. Could you or your husband have told Audrey Ruffin what her responsibilities

were.'

Audrey Ruffin's responsibilities were established by Oliver B. Elders, Sr. when
he hired her in the summer of 1988. At that time, she was given the duties of
caring for my mother-in-law, Mrs. Elders. Ms. Ruffin did not perform
services for my husband and myself, and I believe that, had we directed her to
perform services for my husband and myself, she would not have done so.

2. Could you or your husband have told Audrey Ruffin when to come to work?

A: As I testified at the hearing, when Ms. Ruffin was not at our home, my

husband and I had responsibility for caring for Mrs. Elders. As a result, we
would attempt to coordinate our schedules with Ms. Ruffin to ensure that
Mrs. Elders received needed care.

3. Please provide a break down of the $15300 in back taxes and penalties you paid.
Was this all in connection with the taxes due on the wages of Audrey Ruffin? Are
any additional amounts due?

Form 942 Form 940 Total

Taxes Owed $7,792.72 $1,996.40 $9,789.12

Penalties 1,843.73 499.10 2347,83

Interest 2311.97 666.39 3,17837

Total $12,153.42 $3,161.89 $1531532

166

Forms 942 and 940 relate to the payment of Social Security taxes on wages paid
and federal unemployment taxes for a portion of the total wages paid by Mrs.
Elders. I am advised by the accountant who assisted in this matter that no
additional amounts are due, and that Mrs. Elders may receive a refund
because certain of his estimates of penalties and interest may be overstated
Moreover, the $1531532 includes both the employer and the employee social
security tax payments.

4. If you had not been nominated for this position, when would you and your
husband have paid these taxes?

A: As I testified at the hearing, I regarded Mrs. Elders as the employer of Ms.
Ruffin, and she was paid out of Mrs. Elders's income. Mrs. Elders received
income from retirement benefits and rental property that she owns. That
income was deposited into the joint checking account of myself and my
husband. My husband and I then paid Ms. Ruffin from our joint account.
Mrs. Elder's income was sufficient to cover the payments to Mrs. Ruffin.

I did not regard the payment of social security taxes on the salary of the nurse
employed by my mother-in-law as my responsibility. As a result, I did not
focus on the nature of Ms. Ruffin's services for Mrs. Elders, and any attendant
tax liability that Mrs. Elders may be incurring. Following the increased
attention in this area since January 1993, and as I began to prepare for my
confirmation hearing, I decided it was necessary to address this issue.
Although I do not believe that my husband's failure, under his power of
attorney from his mother, to pay the social security taxes for Ms. Ruffin is my
responsibility, I decided to insist that the taxes be paid prior to the hearing to
avoid any possible issue

5. During testimony before the Committee, in response to a question regarding your
familiarity with the procedures for hiring and paying private health care providers,
you stated that it was your understanding that "... private-duty nurses really are
independent consultants or independent contractors and they handled their own
finances.'*

A letter received on July 26, 1993, by this Committee (see Appendix A), dated April
18, 1989, from the Arkansas Department of Health in response to an IRS inquiry,
indicates that your Department was informed by the IRS that the ADH was in
violation of the law for treating personal care aides as "independent contractors."

(a) Please explain how, in light of this letter, you were still not aware of the proper
withholding practices for personal care aides?

A: As Director of ADH, I was generally aware that the issue of the proper tax
treatment of personal case aides was being raised by the Internal Revenue
Service. In our agency, the matter was being handled by Finance Department
at ADH. I was not aware at the time 6T the criteria for determining when a
home health aide was an employee as opposed to an independent contractor.

(b) If you were unaware of this letter, please state how, as Director of ADH, you
administered inquiries by a federal agency regarding violations of federal law by
your Department.

167

A: I recall that ADH immediately responded to the IRS letter, determined

whether our practices were consistent with the requirements of the law, and
adjusted our practices to ensure compliance.

(c) If you are confirmed by the Senate, please fully state how you would implement
review procedures to ensure mat the Publiciiealth Service is administered in
complete compliance with the law and managed with proper responsibility.

A: If confirmed as Surgeon General, I am committed to maintaining the highest
standards of ethical behavior and compliance with the law both by myself and
the Public Health Service over which I have authority. Also as Surgeon
General, I will impose rigorous controls and oversight as necessary to ensure
proper compliance with all legal, regulatory, and ethical requirements.

6. Could you please supply the Committee with copies of the correspondence from
the ERS to the ADH regarding the issues?

A: I am no longer the director of the ADH, and do not possess copies of the
correspondence from the IRS to the ADH regarding these issues.

SPROLES HOME HEALTH AGENCY

1. Was there any relationship between Tommy Sproles* Home Health Agency and
the Mercy Nursing Home?

A: No, to my knowledge, there was no relationship between Tommy Sproles
Home Health Agency and the Mercy Nursing Home.

2. Were you ever a shareholder in either the Mercy Nursing Home or the Home
Health Agency?

A: No, I was never a shareholder in the Sproles Home Health Agency or the
Mercy Nursing Home.

3. Were Audrey and/or Rose Ruffin ever employed by or connected in any way with
Tommy Sproles and/or the Home Health Agency?

A: No, to my knowledge, neither Audrey nor Rose Ruffin was ever employed by
or connected in any way with Tommy Sproles or the Home Health Agency.

TEEN PREGNANCY

1. You stated as State Health Director....

a. We haven't given abstinence a chance— so how can you say that abstinence won't
work? Further, given these facts, how can you say that the current approach does
work?

168

A: I support abstinence as the best choice for young women. I do not feel that we
can rely only on abstinence messages because this does not provide any help
to those young persons who do decide to become sexually active. For this
reason I believe that information on sexuality and contraception must be
provided along with abstinence information. Programs which have provided
both abstinence and contraception information within a comprehensive
framework— such as the Reducing the .Risk program and the Postponing
Sexual Involvement program have shown both increased postponement of
initiation of sexual activity as well as improvements in contraceptive practice
among those teens who do become sexually active

Provision of family planning programs does not cause sexual activity. Most
teens are sexually active for almost a year before they seek contraception from
a family planning clinic Increases in the funding for family planning and
sexuality education programs followed, not preceded, the increase in teen
sexuality activity and sexually transmitted diseases. The failure of these
programs to stem the problems can be more accurately attributed to the
inadequate funding they have received over the past decade; indeed, the Title
X program currently has only about half the purchasing power it had in 1980.

b. If you had no success in Arkansas in reducing the rate of teen pregnancy, why
should we believe you will have any success in implementing the same plan on a
national level?

A: To the contrary, we did have success, although not as much as I would have
liked, on reducing the rate of teen pregnancy. This is a task which requires
the involvement of teens, their parents, schools, communities and
community leaders and the media which glorify sex as safe and costless and
glamorous. A state health director or Surgeon General can work to coalesce
these forces, but it will not be until they adopt the message that real progress
will begin to be made.

c You have blamed the failure of your plan to reduce Arkansas' teen pregnancy rate
on "Poverty and ignorance and the Bible-belt mentality." Would you please
comment on that?

A: The statement is not in response to the failure of my plan to reduce Arkansas'
teen pregnancy rate but rather is a statement concerning the continuing
increase in the teen pregnancy rate on the national level

2. On the issue of the minority children bom to teenagers, you have been quoted as
asking, "Why should we want a race of black people who are retarded, ignorant and
poor?" (The New York Times, October 15, 1989) Do you really believe that children
bom to teenagers are "retarded, ignorant, and poor"? Jesse Jackson appeared before
this committee yesterday to testify on adoption of African American children and he
told the committee how he was bom to (SIC) teenager, and was later adopted.
Surely you don't mean to imply that all or even most of the children bom to
teenagers are necessarily ignorant or retarded? -

A: Children born to teenagers are 80% more likely to be poor, are 12% more
likely to be a low birth weight baby, and more likely to be in a special
education class. No, I do not mean to imply that all or even most of the
children bom to teenagers are necessarily ignorant or retarded, but we would
like for all children to have two nurturing parents and to be planned and
wanted.

169

3. In February of this year the Washington Post reported you told the American
Medical News that teenage mothers and their babies make up America's newest
slave class. "If Medicaid does not pay for abortions, does not pay for family
planning, but pays for prenatal care and delivery, that's saying "I'll pay for your to
have another good, healthy slave, but I won't pay for your to use your brain and
make choices for yourself...If you are poor and ignorant, you are a slave.
(Washington Post, 2/16/93).

One month later you were quoted as saying. The public assistance tab for teen
mothers and their children came to $26 billion in 1991, up from $19.3 billion four
years earlier. Single, unemployed with no job skills and on welfare, children who
have children constitute America's newest slave class." (Los Angles Times, March 8,
1993)

Could you please elaborate?

A: I am a proponent of access to family planning services for poor women to
enable them to avoid pregnancy if that is their wish. Although we as a
Nation focus our time and resources on health care for pregnant women and
their children, we do not focus enough on preventive health measures such
as family planning that can assist women in planning or delaying their
pregnancies until they are best able to care for their children.

This is evidenced by the fact that in FY 1992, the estimated Federal share of
Medicaid funding for all maternal and infant care was $5.0 billion, while the
Federal share of Medicaid funding for family planning services was just $405
million. In addition, over the last decade, after adjusting for inflation, there
has actually been a decrease in Title X funding for family planning services,
the Federal government's major source of grant funding for family planning
services to poor women.

With regard to Medicaid, although Medicaid expenditures for family
planning services have been increasing, because States use different sets of
income guidelines to determine Medicaid eligibility, coverage for family
planning services for poor women varies greatly by State.

In addition, while Medicaid regulations require States to provide obstetrical
coverage for pregnant women whose incomes are up to 133 percent of
poverty for a period of 60 days post partum, most poor women who are not
pregnant can only receive Medicaid coverage (and therefore reimbursement
for family planning services) if they quality for AFDC And, income eligibility
criteria varies gready from state to state — for example in Arkansas,
individuals are eligible for AFDC payments only if their income falls below 21

percent of the Federal Poverty Guidelines.1

V Medicaid Source Book: Background Data and Analysis (A 1993 Update) A report prepared by the
Congressional Research Services for use by the Subcommittee on Health and the Environment of the
Committee on Energy and Commerce. January. 1993 P. 746

170

4. Upon what sources did you base the statistic that 60% of American' children are
"unplanned and unwanted?"

A: My information source was a publication from the National Center for
Health Statistics using data from the National Survey of Family Growth. In
1988 among never-married women aged 15-44 65% of the children bom to
them were unplanned and unwanted. [39.8% mistimed and 25.4% unwanted]
In this report a pregnancy was classified as "unwanted" at conception if the
woman had stopped, or had not used, contraception for reasons other than
seeking pregnancy, or if she had become pregnant while using contraception
and had not wanted a baby. Births that were wanted but occurred sooner than
desired were classified as "mistimed." "Unintended" births are those that
were either unwanted or mistimed.

171

APPENDIX A

yG-Aastsa* DEPARTMENT OF HEALTH

4»tS*eSTI«Afl»<M«ST"EET - UmjERO«.ARRM<SAS7ZZOS
IBfFMOHE AC 501 teiBXD

81U.CUKT0M
GOVERNOR

April 18. 1989

Hr. Paul Southard

Internal Revenue Service

First Federal Building. Room 430

401 H. Capitol

Little Rock.. AR 72201

Dear Hr. Southard:

'.r-.-f*

This letter is In response to your Inquiry regarding our treatment of Personal
Care Aides. Registered Nurses. Physical Therapist. Speech Therapists. Licensed
Practical Hurses. and Occupational Therapists as "Independent Contractors.'

Our hoiie health agency operates on public funds: a mix of state funds,
re labor seaents from Medicare and Medicaid, and son* Veteran's Admtnl strati on.
As such, we are expected to provide care for people regardless of whether or
not they have a third-party payment source for the care. Our patients are'
typically suffering from a major Illness (cancer, stroke, heart disease, new
diabetes, etc.). or are so frail that they are about to enter a nursing home.
These services are generally the critical factor In the patient's being able
to remain at hone, using family support In a loving environment.

He have been under the belief that a selected group of our "personnel" were
appropriately classified as Independent contractors, since we do not directly
supervise them, but rather provide the* with a Care Plan for their
professional services. They do have the lattltode to refuse assignments, and
to select their own working hours.

However. In reviewing the documentation which you sent to us. we understand
that we should be treating these workers as "employees."

He have met with the Arkansas Department of Finance and Administration, with
our Accounting and Financial Hanagment sections, and with our data systems
managers, and have made the following plans for complying with recent IRS
rulings. As you review these plans, please keep In mind that we are a
statewide organization which must collect Information from personnel In 75
counties of Arkansas.

172

..tTTER 10 HR. SOUTHARD
Apr I) J7. 1989
Page 2

I. He will, pay both our portion and the employees' portion of FICA for the
period January I. 1989 through June 30. 1989. He will do this because we
do not feel that we can guarantee to yo«f that we will have the necessary
withholding systeas 1n place prior to that date.

On Joly I, 1989. we will begin standard withholding for those employees
which we had previously considered "Independent contractors." (This will
necessarily Include aeetlngs with the eaployees. collection of necessary
tax Information, as well as computer changeovers; restructuring of data
systems, etc.)

2. He will process the first batch (both employees' and employers share) of
FICA payments for one group of personnel which comprises the majority
within two weeks. He will phase In FICA payaent for the remaining
Individual employee groups by the end of Hay. He will spend June
accumulating tax information statewide necessary for the withholding
process.

3. He will provide jrou with a status report on June 15. 1989. and on
July 30. 1989.

He hope that this plan Is acceptable to you; we appreciate your calling the
matter to our attention — we honestly thought we were operating In accordance
with applicable rules. If we can provide any further Information, please
don't hesitate to call us.

Sincerely,

Clay Par ton. Dtcector
Divlston of In-Some Services

cc: Nancy Clrsdi
Rob Robinette
Toa S. Butler
Jim Hills

173

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY

SENATOR NANCY LANDON KASSEBAUM

ROLE OF THE SURGEON GENERAL

You were preceded in your role by two surgeon generals who successfully advocated
different public health causes. Dr. C. Everett Koop led a national crusade against
tobacco use and called for preventative measures to curb the spread of HIV. Dr.
Antonia Novella focused the nation's attention on the adverse effects of alcohol
usage and abuse, especially among teenagers.

Q: What are your goals in your role as health advisor to the Nation?

A: The role of the Surgeon General as I see the office and understand it at
the present time is articulated in a document I am attaching to these
responses. (See Appendix A). Some of these views were given in my
opening statement to the Committee. As Surgeon General, my goal
will be to improve the quality of life by:

— preventing chronic and infectious diseases,
including cancer, heart disease, hypertension,
tuberculosis and AIDS;

— reducing teen pregnancy, infant mortality and
morbidity;

— eliminating the serious disparities in health
problems which minority groups experience;

— preventing and reducing the toll of injuries and
disabilities in our society;

— improving women's health; and

— providing care and services for our elderly so they
can live in dignity and comfort during their final
years.

Q. What public health causes do you plan to advocate?

A: I will be a strong advocate for programs outlined in this brief, in addition to
other major public health issues seen as needs by the Congress, President and
the American people.

Traditionally, the Surgeon General has been the nation's health policy advisor.
Under a proposed reorganization of the Office of the Assistant Secretary for Health. I
understand you could be assigned roles different than previous surgeon generals. If
the reorganization occurs, you would be the direct supervisor of the Office of
Women's Health, Minority Health, Disease Prevention and Health Promotion and
Population Affairs.

Q: Is this true? How will your role be different than previous surgeon generals?
Why is there a change in the role of Surgeon General? To whom will you report,
Dr. Lee or Dr. Shalala?

174

A: Under the intended reorganization within the Department's Office of the
Assistant Secretary for Health, the role of the Surgeon General will be
expanded. The Assistant Secretary for Health will remain the head of the
United States Public Health Service, while the Surgeon General manages the
PHS Commissioned Corps personnel system and serves as the health advisor
to the nation.

The expansion of the Surgeon General's role entails placing four programs
within the Public Health Service under the Surgeon General's supervision.
These programs include the Office of Women's Health, Office of Minority
Health, Office of Health Promotion and Disease Prevention, and Office of
Population Affairs. Since these programs are located in the Office of the
Assistant Secretary for Health, a major reorganization and relocation is not
required.

Although I look forward to working closely with the Secretary, I will report if
confirmed to the Assistant Secretary for Health, Dr. Philip Lee, just as my
predecessors have.

Q: What is your top priority for each of the offices you will direct? A large role of
each of these offices is to coordinate activities across the entire Public Health Service.
In your role, will you also try to prevent unnecessary duplication of efforts across
the Public Health Service?

A: I want the opportunity to study the current activities of these Offices in more
detail before I decide the priorities for these programs. I do intend to work
toward preventing the duplication of effort across the Public Health Services.
However, euminating duplication is not enough. Based on my experience in
Arkansas, I know that we must improve the coordination of effort in our
programs and increase flexibility.

TEEN HEALTH

In Arkansas, you initiated different programs to improve the health of teenagers.
You are credited with expanding the number of school based health clinics. In
addition, during you a tenure, the Arkansas teenage pregnancy rate climbed, but at a
lower rate than the nation's.

Q: What are the most pressing health problems facing teenagers today?

A: As I have stated in my testimony, all too often I have seen bright young
people all over this country surrounded by social problems which negatively
impact their health such as drugs, alcohol, violence, homicide, suicide, AIDS
and teenage pregnancy.

The overall health profile of teenagers is distressing especially when
reviewing the morbidity and mortality associated with adolescent's poor or
high-risk health behaviors:

(1) According to data from the CDC, in 1987 and 1988, about three-
fourths of all deaths among VS. young people aged 10-24 years were
related to only four major causes: motor vehicle accidents (36.8%),
homicide (13.7%), suicide (12.1 %), and other injury (11.9%).

175

(2) In addition, over the last decade, drug abuse, alcohol and cigarette
use and unprotected sexual intercourse among adolescents have
become a significant health problem contributing to high rates of
adolescent morbidity.

(3) All too frequently, these health and social problems are interrelated.
As many as one in four adolescents are considered to be "at risk" for
school failure, delinquency, early unprotected sexual intercourse and
substance abuse.

Q: What were the most successful initiatives you undertook in Arkansas to
improve the health of teenagers, and why do you think they were effective?

A combination of various initiatives have contributed to efforts to
improve adolescent health in Arkansas. The key is focusing public
attention the health concerns of young people, educating both public
health personnel and the general public, and making health services
accessible through approaches such as school-based or school-linked
health initiatives.

I think efforts such as the Arkansas "time bomb" initiative and the
community health promotion project are examples of successful initiatives.
The "time bomb" initiative was a joint venture between the Arkansas
Department of Public Health and the local NBC affiliate to target PSA's at
youth. This particular initiative won a Peabody Award. Another example is
the Community Health Promotion Projects which through funding from the
Kaiser Foundation provided support for five community based projects to
work with adolescents in areas that had high rates of teenage pregnancy.

Q: In your role, do you plan to advocate for a Federal program of school based
clinics? If so, what role should the parent play in these settings?

A: Yes, I do plan to advocate for the establishment of school based clinics with
full participation by local communities.

The role of parent in a school based setting is one of partnership with the
health care provider and the school. In Arkansas, no service is provided to
the student without the consent of the parent The parent chooses and
consents to the services provided to their child and works together with the
school and health care provider to keep the child healthy and ready to learn.

TEEN PREGNANCY

Q: I understand that two of the Arkansas School Based Clinics distribute birth
control on site Should all school based clinics do this? If not, who should decide
which programs do?

A: The school based clinics in Arkansas that dispense condoms or birth control
on-site do so at the request of die local school board. This is, and should be, a
local decision of the school board and the school to choose the services to be
offered. No service should be provided to a student without the consent of
the parent.

176

Q: What are the best methods to reduce the rise in teen pregnancy across the
country? Which of these do you advocate?

A: I believe that the best methods include:

(1) Education: Children who are doing well in school are three times less
likely to be teen parents. If children are to do well in school, we must start
with early childhood education for all children, especially for those at greatest
risk. Children that live in poor socioeconomic environments are also more
likely to be teen parents. The combination of doing poorly in school and low
socioeconomic status increases risk nine fold. We must also educate parents
on how to be good parents and how to educate their children. We need
multiple strategies for most adolescents, nurturing parents, supportive
community, education, early and continuous availability of health and
contraceptive services, in addition to hope for the future;

(2) Development and dissemination of health education curricula: These
curricula would be part of a comprehensive health education program which
begins in the early grades at age-appropriate levels. I would include education
on reasons to delay sexual activity, especially targeted to younger adolescents,
but also including complete information on contraceptives;

(3) Support for school based and school linked services: Funding support
would ensure the provision of comprehensive health education and services.
This support would be provided for those communities that request it;

(4) Increase outreach efforts: Outreach efforts would include disseminating
information to demystify clinic procedure as well as to dispel myths and
incorrect information about sexuality and contraceptives. Information would
be delivered to adolescents through group education and familiarization
sessions at clinics, presentations in schools and in other community centers;

(5) Enhanced counseling services; and

(6) Making contraceptives available and accessible to every person who is at
risk of having an unintended pregnancy.

I advocate any and all of these methods in order to help reduce the incidence
of adolescent pregnancy.

Q: During your tenure, the number of abortions for 15 to 19-year-old women
decreased from 2,028 in 1987 to 1,736 in 1991. Why do you think this
happened?

A: The absolute number of abortions for 15 to 19-year-old women is
dropping partly because the number of teen women is declining. Since
all states do not collect information on abortions, accurate national data
are hard to come by, but it appears that this decline is a national
phenomenon.

MATERNAL AND CHILD HEALTH

While in Arkansas, you implemented policies which appear to have improved the
health of mothers and their infants.

177

Q: I understand the percentage of women who did not receive prenatal care in
the first trimester decreased for 335 percent to 28.6 percent from 1987 to 1991.
What programs did you implement to increase prenatal care? What special
initiatives do you plan to address this issues in your role as surgeon general?

A: I'm very proud that the number of women seeking early pre-natal care
increased during my tenure. The major programs implemented in
Arkansas to increase this number were related to increasing Medicaid
coverage from 29% to 185% of poverty and having presumptive
eligibility so pregnant women could be Medicaid covered from their
initial visit to the health department. Secondly, we had excellent
Healthy Babies campaign where mothers were rewarded with coupon
books for coming in for early prenatal care We increased awareness of
the entire community of the need for early prenatal care by involving
our businesses, schools, churches, civic groups and others. We
extended our clinic hours to make services more convenient for
mothers. We improved our education of mothers so they would know
to come in early and to tell their friends about coming in early. We
also improved our public health facilities to make them more user
friendly so women would want to come to our clinics to receive early
prenatal care.

If confirmed as Surgeon General, I plan to address infant mortality
with some of the same strategies developed in Arkansas and other
states. We need to evaluate the best of these programs and make them

available for all states so they can tailor the programs to fit the needs of

their community.

Q: The number of children screened for development and adequate growth
increased dramatically in Arkansas during your tenure. You promoted
screening in a variety of non-clinic settings, including WIC application
centers. Do you plan to address children's health issues in your new role? If
so, what are your plans?

A: Early periodic screening diagnosis and treatment (EPSDT) was
markedly increased during my tenure at Arkansas. This was again
related to making sure that children in the health department received
whatever services they needed, whether it was for WIC,
immunizations or their EPSDT screen. We took advantage of every
opportunity to serve our children.

Secondly, we changed the periodicity schedule for immunizations and
well baby check-ups in the State of Arkansas to make it conform more
to what pediatricians were doing in their offices.

Thirdly, we made EPSDT forms available in physicians' offices and in
health departments so they did not have to be scheduled by DHS, the
administrator of Medicaid in Arkansas. This put more responsibility
on parents, it allowed them to make, their own appointments rather
than just be mailed an appointment time by DHS without regard to
when parents could best keep their appointment. The "no show" rate
for EPSDT decreased.

Fourthly, we increased the awareness and training of our nurses and
nurse practitioners, many of whom could do the screening themselves.

178

I definitely plan to address children's health issues in my new role. I
have been a strong advocate for children's health for many years now
both as a pediatrician, a pediatric endocrinologist and a health director.
I plan to continue these activities. I feel that we cannot educate
children if they are not healthy and we can't keep them healthy if they
are not educated. I will strongly push for continued early prenatal care
for all mothers. I would like for every child bom in America to be a
planned and wanted child. I would-like for that child to be able to be
healthy, educated, motivated and to have hope. I would push for early
childhood education for all children, especially those at the highest
risk. I want to make health services available to all children as a right
and not related to their ability to pay.

I will strongly support those concerns which help to strengthen
families such as early childhood education, parenting education, male
responsibility programs, college scholarships and work for a healthy
environment which will allow children to grow up healthy, motivated
and with hope.

PUBLIC HEALTH AND HEALTH CARE REFORM

Recently, you called for an expanded role for public health in a reformed health care
system. One result of health care reform might be universal insurance for all
Americans and a reduction in die financial burden placed on State and local public
health departments.

Q: Freed from paying for the costs of health care for many persons, what will be the
role of State and the Federal public health in the future? Will there be a need for
new Federal public health resources?

A: It would be premature for me to comment on the roles of the State and

Federal public health care agencies since the specifics of the Presidenfs health
care reform plan are still being finalized. However, I believe that the State
and local public health departments will continue to play a vital role in
meeting the health care needs of their communities.

With regard to additional Federal public health resources, I would not want
to preempt the President on this issue I am sure this will be addressed when
the health care reform plan is announced in the coming weeks.

Q: In your position as surgeon general, what type of reorganization do you plan for
the Public Health Service's Commissioned Corps?

A: My concern is to make sure that the Commissioned Corps uses its resources
to the greatest benefit of the public health I have several ideas in this regard.

(1) We may decide to provide incentives for medical officers to move out of
some administrative positions and into jobs involving the delivery of patient
care. I feel that we should use trained physicians to provide needed care in

179

Indian Health Clinics, and at community and migrant health centers
wherever possible;

(2) Also, we should consider options for revising the Corps policies to attract
even more health care professionals into public service;

(3) Finally, we should look at how the corps could be used more effectively in
case of natural disasters like the catastrophic flood in the midwest

Oj What role, if any, will you play in the health care reform discussions?

A: I don't know the exact role that I will play in health care reform discussions.

1990 ARKANSAS FINANCIAL DISCLOSURE FORM:

Your 1990 Arkansas Financial Disclosure form is missing from the Secretary of
State's office.

Q: Could you provide information regarding the amounts and sources of income
you listed on the 1990 form in addition to your salary as director of ADH?

A: For my spouse, the Little Rock School District would have been listed in
Section 3. The block "more than $12,500" would have been checked.

For myself, Mercy Nursing Home would have been listed. The box marked
"more than $1,000" would have been checked.

GIVING ENDORSEMENTS TO GROUPS
SEEKING GRANTS FROM THE ADH

On at least three occasions you gave written endorsements to groups seeking grants
from the Arkansas Dept of Health during your tenure as director of the agency.

Q: Do you feel endorsements for groups applying for funds from the agency over
which you presided represented a conflict of interest?

A: On the three occasions that are referenced in this question, I do not believe
that my endorsements represented a conflict of interest It is my recollection
that on each of those three occasions, I was unaware at the time that the
endorsement was solicited that ADH would be the disburser of funds.

With respect to the Planned Parenthood letters, my recollection is reinforced
by Nancy Liebbe, Executive Director of Planned Parenthood of Greater
Arkansas. She has written the Committee stating that for the two letters that
she solicited from me, she did not inform me that the grant applications
would be made to the ADH- indeed, she believed on each occasion that the
Centers for Disease Control and Prevention would be funding the grants
directly.

Q: If confirmed as U-S. Surgeon General, would you give written endorsements to
groups applying to the National Institutes of Health for research grants?

A: No.

180

ACCRUED VACATION DAYS AS
CONSULTANT TO US. DEFT. OF HHS:

During your testimony before the Senate Labor and Human Resources Committee
on July 23, 1993 your stated mat you had accrued 60 days of vacation from your job as
director of the state DepL of Health which you used as a consultant with the US.
Dept of Health & Human Services beginning April 18, 1993.

Q: It is my understanding the maximum number of vacation days allowed to be
accrued and carried over annually by Arkansas state employees is 30. Could you
reconcile this apparent discrepancy?

A: It is also my understanding that the maximum number of vacation days that
can be carried over annually by Arkansas State employees is thirty. As of
January 1, 1993, 1 carried over the full thirty days of leave. Thereafter, I earned
leave at a rate of 15 hours per month.

Q: How many vacation days (8 hours per day) did you eventually use as a consultant
with the U.S. Dept of Health & Human Services?

A: 28 days.

SALARY ARRANGEMENTS AS
ARKANSAS DEPT. OF HEALTH DIRECTOR

The Arkansas Attorney General has issued at least three opinions appearing to
conclude the arrangement under which you were paid a salary by UAMS as director
of the ADH, was legally questionable.

Q: Were you notified that you were possibly violating state law by being paid a salary
exceeding the legal cap for authorized salaries to state agency directors?

A: See the answers on "Pay Issue" to Senator Coats' questions.

Q: Since you were being paid by both UAMS and the state health dept, could you
explain how many hours you continued to work as a professor on the staff of UAMS
while holding down the full-time job of state health director?

A: I received a single paycheck from UAMS, where I was a tenured professor of
pediatrics. My understanding was that the ADH contracted with UAMS for
my services. I performed occasional services for UAMS such as publishing
scholarly articles, taking medical students on rounds, and lecturing at UAMS
seminars. I also served on the Human Research Advisory Committee and
was a member of the faculty in the division of Pediatric Endocrinology and
performed duties such as clinics rounds and consultations with faculty,
students and housestaff. I estimate that I averaged in the vicinity of 8-10
hours per week on such activities.

181

AUTHORIZATION OF TOM SPROLES'
CONSULTING CONTRACT WITH ADH:

In early 1990, as director of the ADH, you reportedly authorized a consulting fee of
$18,000 with Tom Sproles who had donated his private Central Arkansas Home
Health Agency, to the state health department. You also approved a contract by
which the ADH would lease Sproles' building housing his agency for five years at
$21,063 annually.

Q: Could you explain the reason for approving this consulting fee for Sproles as well
as the arrangement by which the ADH acquired Sproles' home health agency?

A: In early 1990 two home health agencies in Pulaski County offered their
agencies to the Arkansas Department of Health as both of these
agencies were failing in terms of cash flow. Prior to being able to
negotiate a deal one of these agencies failed leaving no one in Pulaski
County that provided many in-home health services to the poor,
minorities and the underinsured. Mr. Sproles's agency fell into this
category. Since he had provided services in this community for a long
period of time, he wanted to be assured that the personnel and the
patients were cared for and that the transition occurred in an orderly
manner. The ADH did not have a Home Health Agency in Pulaski
County. We wanted to serve this county and needed a consultant with
experience to help with patient and physician recruitment. Therefore,
we hired Mr. Sproles.

As to the building lease, the State Building Service evaluated and
approved the building and equipment lease for the $21,063 annually.

ARKANSAS DEPT. OF HEALTH FAILURE
TO PAY SOCIAL SECURITY. TAXES FOR EMPLOYEES:

Q: Was the Arkansas Department of Health (ADH) cited by the IRS in 1989 for
failure to withhold Social Security taxes for personal home care aides who were
employed and paid by the ADH?

A: See the answer to Senator Coats' question number 5 under "Social Security."

Q: To the best of your knowledge, how much in back taxes and penalties did the state
pay?

A: As I recall, ADH paid back social security taxes in the approximate amount of
$200,000 to $300,000. The IRS did not assess penalties.

Q: Were you, in your position as director of ADH, held accountable for this
omission?

I was not held accountable for this omission. I believe that the ADH practice
of not withholding Social Security taxes predated my appointment as Director
of ADH. When I learned that the IRS had questioned ADH's failure to
withhold Social Security taxes, I directed my staff to respond immediately and
appropriately to the IRS inquiry. I believe our response satisfied the Internal
Revenue Service.

182

PULSE HOME CARE

In 1992, during your tenure as ADH director, the ADH entered into an exclusive
contract with Pulse Home Care, a Little Rock home care staffing agency.

Q: Did this arrangement violate Arkansas government contracting laws and ethics
when there were at least 6-7 firms in the state-which could have provided this type
of personnel staffing?

A: No. Information was sent to all staffing agencies in the state. Two of
the three firms made offers. Only one agreed to enter into a contractual
relationship with the department

Q: What criteria did you and your senior ADH staff use in deciding to contract with
Pulse to provide home care staffing?

A: There were two criteria: 1) the agency had to be in the staffing business;
and 2) the agency could not be a home health agency.

Q: Did you personally authorize this contract between Pulse and the ADH?

A: No. Contracts are usually handled by the local program person and
presented to the Deputy Director. All contracts of mis nature have to
be presented to a legislative committee for their advice. Only if there
was a question or if problems arose were they discussed with me. I
would then present the contract before the legislative committee rather
than the local program director.

In this case, the initial contract was approved by the legislative
committee. Only upon an amendment of the contract did I have to

appear before the legislative committee. There were several home
health agencies in the state objecting to the contract at that time.

Q: How much did Pulse Home Care bill the ADH per hour for home care patient
staffing?

A: The billing varied depending on the area of the state. The range is between
$9 - $24 per hour. The usual rate was $18 per hour.

Q: How many patients has the ADH referred to Pulse Home Care since the
contractual arrangement began?

A: Since November 1992, the total number of patients served for continuous
care is forty-four. There are currently twelve patients being provided
continuous care. In addition. Pulse may provide nursing staff for occasional
intermittent visit services for patients on weekends or in areas where
recruitment of nurses is particularly difficult. Pulse provided staff which
made approximately 2,000 visits during FY "93.

183

Q: What percentage of the private home care industry business does this represent?

A: For continuous nursing care, it represents eight to ten percent since there are
less than 150 continuous care patients in the state. Of the total home health
care, the Pulse contract represents 0.1%.

NARCOTICS FOR MEDICAL USE

You have been quoted as advocating the use of marijuana for patients suffering
from glaucoma, cancer, and AIDS.

Q: If confirmed as Surgeon General, would you advocate the use of narcotics for
medical use that are currently prohibited by the Federal Government?

A: Research is currently being performed as to the therapeutic benefits of
marijuana for such diseases as glaucoma, cancer, and AIDS. I believe
the Secretary is planning to review the issue of marijuana's use for
those purposes. I support such a review and would, therefore, defer a

conclusive statement on the matter until the review has been
completed.

I would not, however, advocate any action that was contrary to law or,
even if lawful, contrary to the policy of the Department of Health and
Human Services.

TEEN PREGNANCY INCREASE

Its been reported that during your tenure as State Health Director, Arkansas' teen
pregnancy rate and the incidence of sexually transmitted diseases rose dramatically.

Q. Could you state the actual pregnancy rate and the rate of sexually transmitted
diseases during your term and its relation to the national average?

A: Statistics concerning "teen pregnancy" include live births, induced abortions,
fetal deaths, and spontaneous abortions of 15-19 year-old women. "Teen
fertility" represents the number of live births to women ages 15-19 divided by
the total number of women ages 15-19. "Teen pregnancy" represents the
number of live births, abortions, and an estimate of fetal deaths to women
aged 15-19 divided by the total number of women aged 15-19.

Arkansas 1987 1988 1989 1990 1991

teen pregnancy.

105.5

108.6

113.0

118.9

118.4

teen fertility

683

70.8

772

79.9

77.8

"U.S.A.

teen pregnancy.

105.8

110.8

n/a

teen fertility

50.6

53.0

573

59.9

n/a

184

With regard to sexually transmitted diseases (STDs), only cases' of syphilis and
gonorrhea are recorded age-specifically at the CDC. (Rate is the number of
cases (males and females) ages 15-19 per 100,000.)

U.S.A. 1987 1988 1989 1990 1991

syphilis

19.2

21.8

24.9

29.9

29.8

gonorrhea

1025.9

10325

-10525

1060.6

1098.6

Arkansas

1987

1988

1989

1990

1991

syphilis

gonorrhea

1500

1400

1300

1400

1222

•Arkansas Department of Health

-National Center for Health Statistics, CDC, DHHS

Q. How do you explain this in terms of your emphasis on birth control counseling
and free distribution of condoms?

A: Decreases in teen fertility do not happen overnight. But from 1987 -1990, teen
fertility in Arkansas increased at a slower rate than that in the U.S. The
changes may have happened faster if more of the programs and approaches I
sought had been implemented. Throughout the state there are 24
comprehensive school health service centers, and 22 schools are on the
waiting list for funding to implement already approved student health
centers. Only 4 centers currently offer contraceptives as part of
comprehensive health services, hardly enough to have an effect on statewide
statistics.

INCOMPLETE REAL ESTATE HOLDINGS

It appears that the real estate holdings you listed on the Senate financial disclosure
form are incomplete and in some cases, cany an incorrect address for individual
properties.

Q: Could you please provide an updated list of real estate properties owned by you
and your husband that include correct addresses for each property?

A: Attachment B to these responses is a chart, previously provided to Senator
Coats, which updates information on the real estate properties owned by
myself and my husband.

185

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY

SENATOR JUDD GREGG

SCHOOL-BASED CLINICS IN ARKANSAS

1. What proportion of the school districts in Arkansas had school-based
clinics in 1990, 1991, 1992 and 1993?

A: See Chart Below

School-Based Clinics in Arkansas

1990 1991 1992 1993

# of schools with

SBCs 8 23 24 24

# of school districts

with SBCs 5 14 15 15

# of school districts

in Arkansas 328 323 320 316

Proportion of School

District with SBCs 15% 4.4% 4.4% 4.4%

Q: How many individual schools and individual school districts, in those
year in Arkansas had school-based clinics?

A: See Chart in response to above question.

3. I am aware that the teenage pregnancy rate in Arkansas during the years 1987-
1991 went up at about the same rate as the national rate. Has anyone ever studied
the teen pregnancy rate within the school districts in Arkansas that had school-based
dinks and compared that to the rate for the remainder of Arkansas? If so, what
were the results?

A; These studies are presently being done.

4. In Arkansas, some school-based clinics dispense contraceptives and others do not.
What proportion do? Is there any evidence that the rate of teenage pregnancy in
those that do distribute condoms is lower than in those that do not? If so, please
describe it

A: Only 4 schools in Arkansas dispense contraceptives. Studies are incomplete
and are presently being done.

5. Do you have any non-anecdotal evidence that school-based clinics are an effective
way to bring down the rate of teenage pregnancy? If so, could you please describe it?

186

A: Yes. A school-linked program, designed and administered by The Johns
Hopkins School of Medicine and carried out with the cooperation of the
administrators of four Baltimore Public Schools, provided sexuality and
contraceptive education, individual and group counseling and medical and
contraceptive services. An evaluation of the program found that, in addition
to increases in contraceptive use and decreases in pregnancy, initiation of
sexual activity was delayed an average of seven months. Another evaluation
of six diverse school-based clinics found that education on pregnancy and
AIDS prevention, in combination with contraceptive services, increased
contraceptive use among sexually active students. There were no significant
differences between clinic and nondinic sites with respect to sexual activity
rates.

Zabin, VS., et aL, "Evaluation of a Pregnancy Prevention Program for Urban
Teenagers", Family Planning Perspectives. May /June 1986.

Kirby, D., et al., "Sue School-Based Clinics: Their Reproductive Health
Services and Impact on Sexual Behavior", Family Planning Perspectives.
January/February 1991.

BANKING RELATED QUESTIONS

6. You were reprimanded by the Comptroller of the Currency for unsafe and
unsound banking practices as part of votes you made as a member of the Board of
Directors for an Arkansas bank. Were you ever sued in relation to your work on
any bank board? If so, could you please describe the complaint against you, your
explanations for tine conduct, the facts of the matter, and the disposition of the suit?

A: In the spring of 1989, outside investors achieved a "hostile" takeover of the
NBA As a result, in or about March 1989, a majority of the directors of the
NBA including myself, were removed as directors by vote of the
shareholders.

Following that removal, the new directors caused the NBA to sue the former
executives and board members, alleging various breaches of duties to the
NBA.

The complaint was filed in or about 1992.

Thereafter, defendants filed a "Joint Answer and Counterclaims,'' denying
that the former officers and directors had engaged in any improper conduct or
breach of duties to the NBA To the extent that applicable bank laws and
regulations may have been violated, such violations occurred without the
knowledge or intent of the outside directors.

I believe that all of the former executives and board members have now
agreed on settlement terms with the National Bank of Arkansas. Pursuant to
that agreement the settlement terms are confidential.

I note that on July 21, 1993, in response to newspaper articles relating to this
lawsuit, the Davidson Law Firm, Ltd., which represented the plaintiffs in this
matter, issued a statement. In that statement, plaintiffs' counsel state-

With respect to Dr. Joycelyn Elders, she was joined as a party
defendant in her representative capacity as a former outside

187

director of National Bank of Arkansas and National Banking
Corporation from 1981 through March 29, 1989 at which time an
entirely new Board of directors was elected by the shareholders.
Dr. Elders was sued only in her representative capacity as a
former director of the bank and holding company. There were
no allegations of personal wrongdoing against her individually
and no allegations of bank fraudjar common law fraud against
her or any of the other defendants. The lawsuit sought civil
money damages from all the former board members. Fraud was
not alleged in the lawsuit

Both the bank officers and its attorneys have a high regard for
Dr. Elders personally, professionally, as a physician and a public
servant.

TEEN PREGNANCY

7. During your confirmation hearing, you listed the following as the causes of the
rising teenage pregnancy: (1) in earlier times, more teenagers were married than
currently, (2) children are now going into puberty earlier than previously, (3) 70
percent of our teenage pregnancies occur between three and five o'clock in the
afternoon, when the children are home, and (4) children are now poorer than they
were before- Is this an accurate representation of your views?

A: Yes, but I would like to expand on my answer.

Each year in America more than one million girls between the ages of 10 - 19
years become pregnant Many of these young women are unmarried. In
addition to the causes of rising teenage pregnancy listed in my testimony are
(1) increasing sexual activity among teens, (2) earlier age of starting sexual
activity, (3) younger teens are less likely to use contraceptives, (4) lack of
knowledge of contraceptives and (5) increasing social problems impacting the
behavior of adolescents. I believe we must educate our children so that they
will make responsible decisions.

8. In addition to those causes in Question 7, are there any other causes of the high
rate of teenage pregnancy in the United States, in your opinion? Please explain.

Yes. Adding to the increased pregnancy rates in the VS. is a lower level of
educational attainment, increased drug and alcohol abuse, lower socio-
economic status, the lack of health education in our homes and in our
schools, and less community involvement and family support for
adolescents.

9. I was interested in your statement that 70 percent of teenage pregnancies occur
between three o'clock and five o'clock in the afternoon. I am interested in looking
into that further. Could you please supply me with the source for that statistic.

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A. The well known Kantner and Zelnik surveys of adolescent women found
that more than 75 percent reported their first sexual encounter occurred in
either their own home, their partner's home or a friend's home. A
comparable proportion reported their most recent sexual encounter also
occurring in one of those three places. The most important point, however,
is the absence of parental supervision. For example, a classic study (Hogan
and Kitagawa) found that adolescent girls were 76 percent more likely to be
sexually active if parental supervision~of dating was lax rather than strict.

NURSING HOME RELATED QUESTIONS

10. In your confirmation hearing, you said that the Arkansas Health Department
had no relationship to the nursing home in which you worked. Did the Health
Department pay Medicaid claims by the home or its residents? Did the Health
Department conduct any licensing, quality assurance, or sanitation activities in
regard to the home? If so, please give details.

A: The Arkansas Department of Health does not have any involvement with
the payment of Medicaid claims. The Arkansas Department of Health does
not conduct any licensing, quality assurance, or sanitation activities in regard
to nursing homes.

11. Did you ever visit the home in your capacity as Director of the Arkansas Health
Department? If so, please explain.

A: I did not visit the Mercy Nursing Home in my capacity as Director of the
ADH

12. Did you ever supply consultation to the home by telephone, or to its
residents, while on the job at the Arkansas Health Department? If so, please
explain.

A: I do not recall ever supplying consultation to the home by telephone, or to its
residents, while on the job at the ADH

QUESTIONS RELATED TO TAXES

13. In the hearing, you seemed to say that money was transferred from Mrs. Elders'
accounts, of which your husband was guardian, into die joint checking account of
you and your husband. The money was then paid by you or your husband to the
nurse Is that accurate? If not, please explain.

A: Mrs. Elders received income from retirement benefits and rental properties
that she owned. That income was deposited into the joint checking account
of myself and my husband. My husband or I then paid Ms. Ruffin from our
joint account Mrs. Elders income was sufficient to cover the payments to Ms.
Ruffin.

189

14 Why didn't your husband issue the money to the nurse directly from his
mother's accounts, instead of first transferring the money to your joint account and
then issuing it?

A: See response to Question 13.

15. In paying the nurse, was the money used tcrpay her your money, your husband's
money, or Mrs. Elders' money?

A: The money used to pay Ms. Ruffin was Mrs. Elders' money.

16. In your confirmation hearing, you seemed to say that you were not aware of the
fact that the law requires the payment of Social Security taxes until the past few
weeks. Is that accurate? To ask the question another way, during the time when
you were issuing checks to the nurse for nursing care, did you ever know that
failure to pay Social Security taxes was a violation of the law? During that time, did
anyone ever tell you that Social Security taxes were due on the salary paid to the
nurse?

A: As I testified at the hearing, I did not regard the payment of social security
taxes on the salary of the nurse employed by my mother-in-law as my
responsibility. As a result, I did not focus on the nature of Ms. Ruffin 's
services for Mrs. Elders, and any attendant tax liability that Mrs. Elders may be
incurring. Following the increased attention in this area since January 1993,
and as I began to prepare for my confirmation hearing, I decided it was
necessary to address this issue. Although I do not believe that my husband's
failure, under his power of attorney from his mother, to pay the social
security taxes for Ms. Ruffin is my responsibility, I decided to insist that the
taxes be paid prior to the hearing to avoid any possible issue.

17. In your own words, why weren't the taxes paid?

A: Ms. Ruffin was hired by my father-in-law, not by my husband. When my

father-in-law died, my husband simply continued the arrangements that had
been established by my father-in-law, without attention to whether any
additional requirements were necessary. After the attention given to this area
earlier this year, we focused on the problem and paid the back taxes, penalties
and interest

18. Who paid the back taxes to the IRS? Whose funds were used to pay those back
taxes?

A: The back taxes were owed to the IRS by Mrs. Elders, who is the employer.
Mrs. Elders is 97 years old, has Alzheimer's disease, and is not currently
competent to handle her own financial affairs. My husband acted on her
behalf under the power of attorney that she granted to him when she was
competent.

In light of the desire to resolve this matter rapidly, taxes were paid out of
available funds. Appropriate accounting adjustments will be made to reflect
the payment of these taxes from Mrs. Elders's funds.

190

19. Did you or your husband ever take a tax deduction or claim an exemption for
Mrs. Elders? Did you ever claim Mrs. Elders as a dependent? If yes to either
question, please supply details.

A: My husband and I filed joint tax returns. We did not take a tax deduction or
claim an exemption for Mrs. Elders on our return. We did not claim Mrs.
Elders as a dependent

DR. MALAK

20. Would you please describe in detail your relationship and dealings with Dr.
Fahmy Malak.

A: I have known Dr. Fahmy Malak in his capacity as a medical examiner and as
an employee in the ADH's AIDS program.

As Director of the ADH, I was Chairman of the State Medical Examiner's
Commission. Following some questions concerning Dr. Malak's role as the
Arkansas State Medical Examiner, the State Medical Examiner Commission
retained outside experts to review Dr. Malak's office and his conclusions in
several cases. In November 1988, we received a report from the outside
experts, generally supportive of Dr. Malak. The principal area that the experts
questioned was the adequacy of the staffing level at the Office of the Arkansas
State Medical Examiner. In or about March 1991, supervision of the Arkansas
State Medical Examiner was transferred to the Arkansas State Crime
Laboratory Board. I am not a member of mat Board.

In or about September 1991, Dr. Malak was hired as an employee in the ADH's
AIDS program. I believe that he was hired through the ordinary hiring
processes, including submission of an application, interviews, and
recommendation by a hiring paneL

I have no personal relationship with Dr. Malak.

21. Did you ever help exonerate Dr. Malak of charges of negligence, and recommend
him for a raise? Did you ever hire Dr. Malak to head the Health Department's AIDS
Program?

A: I have never helped exonerate Dr. Malak of charges of negligence. As noted
in response to Question 20, Dr. Malak is not the head of the Arkansas Health
Department's AIDS Program. He was an employee within mat program.
After the death of the laboratory director. Dr. Malak became a clinical
consultant for the laboratory.

On July 16, 1993, 1 received a memorandum from Robert L. Horn, Director of
the State of Arkansas Public Health Laboratories. That memorandum states
in part as follows:

Dr. Malak is functioning as a clinical consultant to the
laboratory's clients, Le., local health units, hospitals, clinics and
other private providers. In this capacity, he advises clients to
assure that the appropriate tests are ordered and assist them in
interpreting clinically significant results.

191

He is a knowledgeable clinician and relates well to laboratory
clients. He screens selected laboratory results to assure that
values are consistent with expectations. His consultations with
users have satisfactorily resolved clients questions when rare or
unusual results were reported.

Dr. Malak is the first clinical consultant available to the
laboratory and his function in this capacity has been most
beneficiaL

PAY ARRANGEMENTS IN ARKANSAS

22. An allegation has been made in the press that you were paid at the Arkansas
Health Department under an arrangement that was questionable. According to the
allegation, you avoided a statutory cap on state salaries by receiving salary from
more than one state source simultaneously, the Health Department and the
University of Arkansas. Would you please give your side of those allegations.

A: See answers to Senator Coats' questions on "Pay Issue"

CONDOMS

23. With regard to the defective condoms referred to in your confirmation hearing,
where in the Untied States were the defective tots distributed?

A. According to AnseU, condoms like those distributed by the Arkansas
Department of Health, were distributed in the District of Columbia and
Guam, and in twenty-seven states [Alabama, Arizona, Arkansas,
California, Colorado, Florida, Hawaii, Illinois, Indiana, Iowa, Kansas,
Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri,
New Jersey, New Mexico, New York, North Carolina, Oregon,
Pennsylvania, Texas, Vermont, Virginia and Washington.] A number
of the customers in those locations were federal entities (e.g., military
bases and hospitals) and, as well, a number of college/ university health
clinics, county health departments and state health departments.

24. Please explain your reasoning in deciding not to issue a notice to the public
warning them of the defective condoms.

A. Senior level staff at the Arkansas Department of Health were involved
in the decision not to publicly announce the recall of the condoms.
The Deputy Director for Administration, the Deputy Director for
Services, Department General Counsel, the Director and the Medical
Director of Maternal and Child Health, and Division Directors of the
Divisions of Pharmacy Services, Reproductive Health Services, and
AIDS and STD Services all participated in discussions which came to
that conclusion. Three meetings were held, two in July, and the third,
in August, 1992, following notification to the Department of Health by
FDA of the results of its testing of Ansell's condoms. At all three
meetings, public notification was discussed. At each of the first two
meetings it was determined not to do public notification because, to my

192

knowledge, the FDA had not completed testing on the condoms. At
the third meeting, after lengthy deliberation, a unanimous decision
was made not to make a public notification because of the overriding
public health risks. The Department senior staff recommended that
the risks associated with the failure generally to use condoms far
outweighed the risks associated with the use of condoms with a higher
than acceptable potential failure rate. I agreed with my senior staff on
the basis of their unanimous recommendation.

VARIOUS QUOTATIONS

25. During your confirmation hearing. Senator Coats read a quote attributed to you
in the LA. Times. The quote referred to a belief that pregnancy was God's
justification for fornication. You said, essentially, that you had been misquoted. If
possible, please supply the correct quote and what you meant to say.

A: See answer 8 under Abortion, Senator Coats.

26. Did you ever say that "most of our society believes that a baby is God's just
punishment for fornication"?

A: See answer 8 under Abortion, Senator Coats.

27. Did you ever say, "We would like for the right-to-life, anti-choice groups to really
get over their love affair with the fetus and start supporting the children."?

A: See answer 10 under Abortion, Senator Coats.

28. Did you ever comment to Arkansas legislators when they rejected a tax increase
on cigarettes, "You sold our children out to the tobacco industry."

A: During the 1993 Session of the Arkansas General Assembly, I attempted to
increase taxes on cigarettes and smokeless tobacco products to fund some
children's programs as well as increasing funding for elderly programs and a
cancer registry in the state. The statement was made following a committee
hearing in which I was unsuccessful in getting committee approval for the
proposed tax increase. The entire Arkansas legislature was never given the
opportunity to vote on the proposal. The statement was directed to those
members of the committee that blocked the proposal.

29. Did you ever characterize abortion foes as part of a "celibate, male-dominated
church, a male-dominated legislature and a male-dominate medical profession."?

A: See answer 11 under Abortion, Senator Coats. This entire statement was
made during that speech.

193

30. Have you ever publicly referred to your opponents as "non-Christian" or "un-
christian."?

A: See answer 7 under Abortion, Senator Coats.

31. Have you ever publicly referred to your opponents as having "slave-master
mentalities"?

A: See answer to Senator Coats' Question 9 under "Abortion."

32. Please feel free to comment upon, justify, or place in context any of the above
quotations.

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY

SENATOR JAMES M. JEFFORDS

Q The State of Vermont has the fourth highest incidence of breast cancer in the
United States. Therefore, we in Vermont are understandably looking for any steps
that can be taken to help reduce the incidence of breast cancer, improve educational
efforts and access to health care in this regard As Surgeon General, what type of
strategy would you pursue to achieve these goals?

A: I am aware mat breast cancer is a particularly serious problem in Vermont. I
know that women's health, including the problem of breast cancer
prevention and control, are a major priority for Secretary Shalala and within
the Public Health Service.

This spring, the Centers for Disease Control and Prevention (CDC) in
collaboration with the Food and Drug Administration and the National
Cancer Institute developed the National Strategic Plan for Earlv Detection and
Control of Breast and Cervical Cancers. This plan addresses such areas as
public education, professional education and practices, and quality assurance.
The Public Health Service, in particular CDC, is working with the States as
well as professional and voluntary organizations to assure that an organized
system of services are made available to all women.

194

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY

SENATOR EDWARD M. KENNEDY

1. You referred to some of your Arkansas opponents as having "a love affair with
the fetus" and being the "very religious non-Christian" right. You also
characterized abortion foes as being "a celibate, male-dominated church, a male-
dominated legislature, and a male-dominated medical profession" and as being
people who "love little children as long as they are in someone else's uterus." In
making these statements did you mean to denigrate the views of millions of
Americans who are sincerely anti-abortion?

A: I am sorry for any offense that I may have given to the many

Americans who sincerely oppose abortion and who also care deeply
about the well-being of mothers and children. In Arkansas, I have
worked closely to develop constructive programs to prevent teen
pregnancy and to promote maternal and child health with many
individuals of good will who also oppose abortion on religious
grounds. While I do not share their religious attitudes on this issue, I
view every abortion as a failure, and I look forward to working closely
with abortion opponents and pro-choice advocates on a common
agenda of good health for mothers and children and prevention of
unwanted pregnancies.

2. In your decision not to publicly announce the recall of the condoms that were
thought to be potentially defective, you were following the unanimous
recommendation of the staff of the Arkansas Department of Health, were you not?

A: Yes. The bureau directors and the division of reproductive health
made that recommendation to me and I carefully evaluated and
accepted it

3. And at that time you didn't actually know the condoms were defective, did you?
The FDA had not tested them, and you had conducted your own recall based on five
complaints over a period of approximately 2 years. Is this correct?

A: To the best of my knowledge, the FDA had not completed testing on
the condoms.

195

RESPONSES OF M. JOYCELYN ELDERS, M.D.

QUESTIONS SUBMITTED BY

SENATOR PAUL WELLSTONE

1. Dr. Elders, I applaud your decision to spend part of your training at the University
of Minnesota. Right away I know we have nOTeason to question your judgment.
Can you discuss with us your motivation for focusing on pediatrics in your medical
training?

A: I was the oldest of eight children. I have always wanted children to be able to
grow up healthy, educated, motivated, and to have hope for the future. I had
excellent mentors in pediatrics during my training as a medical student as
well as during my internship at the University of Minnesota. I have always
felt that as a physician, the things that you would do for children would last a
lifetime.

2. Dr. Elders, I have received many letters of support for you. I'd like to submit an
alphabetical listing of those groups for the record. Of particular interest to me was a
letter from Erima J. Vaughan in Hempstead, N.Y., which I shared with you. She
urges me to vote for your confirmation, saying that she is the single mother of two
boys, and like you, is a woman of color what had to learn to speak plainly. She's
proud of the fact that, as she says, her two sons "date, but no girls got pregnant We
must help young people understand the dangers of AIDS or an unwanted
pregnancy," she concludes.

Can you discuss your interest, as Director of the Arkansas Department of Health, in
educating young people about the importance of knowing how to protect
themselves from diseases and unwanted pregnancy?

A: As the Director of the Arkansas Department of Health I found that Arkansas
had the second highest rate of birth to teenagers in the United States. The
United States has a pregnancy rate which is twice that of Canada, and ten
times higher than Japan. As I evaluated the literature and talked to people
who had been working in this field for many years, I found that there were
several themes that were common to all successful education and pregnancy
prevention programs.

First, you must start early if you want to make a difference with children
through early childhood education. Second, you must educate them about
health by having comprehensive health education from kindergarten
through twelfth grade. Third, you must educate parents. Fourth, you must
involve the young men and teach them to be responsible Fifth, services
need to be available for the children where they are - in school. And last,
they need to have hope for the future. I feel that the only place for all
children to have an equal opportunity for access to health and education is at
school. I therefore began to work with the education community to try and
make services available for all children at school, the place where they spent
most of their day. The services are available, they are easily accessible, they
are affordable, and they should be age appropriate.

3. Minnesota as you know is home of the nation's oldest school-based clinics. In
fact they are celebrating their 20th anniversary this fall, and we hope you may be
able to join us in Minnesota to mark the occasion. Would you tell us what role you
will advocate for school-based clinics if you are confirmed as Surgeon General?

196

The role that I would advocate for school-based clinics if I am confirmed as
Surgeon General would be to serve a very important role in providing
primary, preventive health services on site. These services should include
primary preventive health care, education, nutritional educational services,
reproductive health services, treatment of minor injuries, sports physicals,
and any other services that would be desired by the community and the
school based on the needs of the children. I strongly support involving the
community, and I feel that school boards should decide if they want a school-
based health service. School boards should decide the services they would
like to have available in their clinics, and parents should make a decision
whether their children should use the school-based health services. To be
successful, school-based clinics need to involve the entire community.
Churches, businesses, parents and all other available resources in the
community must help children be able to lead successful productive lives. I
do not feel that you can educate children if they are not healthy. And you
can't keep them healthy if they are not educated. We have copied many of
the wonderful attributes of the first school based clinic started in this country
in Minnesota, and we are very pleased with the things they've done to make
a difference in children's lives over the past 20 years.

4. Dr. Elders, I admire your hard-fought accomplishments. It is rare that we have a
nominee who is so well-suited to face the challenges of the job ahead. You know
about poor access to health care, about rural poverty and the need for expanding
primary care services. I envision you, with eloquence to match your knowledge and
experience, as a Surgeon General in the grand tradition of C Everett Koop, stirring
the nation's conscience to do what we need to do. Can you describe how you hope
to move the nation's health agenda forward during your tenure, and which issues
you find the most compelling?

A: This question has been addressed in question No. 1 of Senator Kassebaum. I

hope that I will have the eloquence and the high profile of Dr. C Everett
Koop and be able to address the multiple issues which will be on our nation's
health agenda during my tenure. I feel the most compelling issue before us at
this time relates to the issues surrounding AIDS , having unplanned,
unwanted children, and certainly making health care accessible for all
Americans.

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ATTACHMENT A

The Rol* of the Surgeon General

The overall mission of the Public Health Service, the principal
health agency of the Federal government, is the protection,
improvement, and advancement of the health of all the American
people. The Surgeon General serves as the principal Federal
health advisor to the Nation on public health matters. As a
public health advocate, the Surgeon General has a pivotal role in
shaping and articulating the public health priorities that serve
to protect and improve the health status of Americans.

DETERKHfAXTS OF HEALTH

What determines our health status? There are four principal
determinants of health:

1. Genetics - One's genetic makeup contributes to a
susceptibility for certain morbidities and is the
principal agent for others, such as Tay-Sachs disease
and sickle cell anemia.

2. Behavior - Behavior and health are strongly linked.

A growing body of evidence links a handful of personal

health behaviors to the leading causes of death in the

United States: heart disease, cancer, cerebrovascular

disease. injuries, and chronic obstructive pulmonary

disease. Smoking alone contributes to one out of every

six deaths in the United States. Failure to use safety

belts end driving "While intoxicated are major

contributors to motor vehicle fatalities. Physical

inactivity and poor nutrition contribute to coronary

atherosclerosis, cancer, diabetes, osteoporosis, arxi

other common diseases. Certain sexual practices

198

increase the risk of unintended pregnancy, sexually
transmitted diseases, and acquired immunodeficiency
syndrome . ( 1 )

3. pea lth care - Access to health care certainly
affects one's health, particularly access to clinical
preventive services. Preventive measures which have
made a tremendous difference in our overall health
status include prenatal care, mammography and clinical
breast examination, the Pap test for early detection of
uterine cancer, and immunizations. (2)

4. Environment - Our health is greatly affected by what we
drink, eat. breathe, and are exposed to through the
environment. Additionally, our health is affected by
our social environment - our family, socioeconomic
status, and the availability of social support
services within the community.

GOVERNMENTS ROLE IN HEALTH

Many of the major improvements in the health of the American
people have been accomplished through public health measures.
Control of infectious diseases, safe food and water, and maternal
and child health services are only a few of the public health
achievements that have prevented countless premature deaths and
improved the quality of American life.

The mission of public health is defined as fulfilling society's
interest in assuring conditions in which people can be healthy
The core functions of public health agencies at all levels of
government are assessment, policy development, and assurance. (3)

Assessment

An understanding of the nature and extent of community health
needs is a fundamental prerequisite to sound decision-making

199

about health. Public health assessment involves systematic
collection, assembly, analysis, and dissemination of available
information on the health of the coominity. including statistics
on health status, cccomunity health needs, and epidemiologic and
other studies of health problems. (3)

Policy Development

Policy development is the process by which society makes
decisions about problems, chooses goals and the proper means to
reach them, handles conflicting views about what should be done,
and allocates resources. Public health agencies bear the
responsibility of ensuring that the public health interest is
served. Public health leaders must raise crucial questions that
no one else raises; initiate communication with all affected
parties: consider long-range issues in addition to crises; speak
on behalf of persons and groups who have difficulty being heard
in the process; and build bridges between the various
constituencies. (3)

Assurance

Assurance is making sure that necessary public health services
are provided to reach agreed upon goals, either by encouraging
private sector action, by requiring it. or by providing services
directly. Assurance involves seeing to the implementation of
legislative mandates as well as maintaining statutory
responsibilities. It includes developing adequate responses to
crises, sustaining basic services. regulating services and
products, and maintaining accountability by setting objectives
and reporting on progress. (3)

PRESCRIPTIONS FOR IMPROVEMENT

As Surgeon General. I have six prescriptions for continued
protection and improvement of the health of Americans.

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Prescription ♦! : A pound of prevention

If an ounce of prevention is worth a pound of cure, let's aim for
a pound of prevention! It is time that every American knows
that:

1) Our leading health problems are preventable, and

2) It is easier and cheaper to prevent health problems.

Indeed, it as estimated that one out of three premature deaths
and two out of three hospitalizations are related to no more than
six risk factors: tobacco use. alcohol and other drug use.
physical inactivity, inadequate nutrition, high blood pressure,
unintentional injury, and gaps in basic health care. (4)

Prescription 42: Health education in the clinic, classroom.
and community

Prevention of health problems largely depends on awareness and

knowledge of risk reducing and health promoting behaviors.

Primary care clinicians should giva greater emphasis to

counseling on personal health practices. Schools should provide

comprehensive, sequential, and age appropriate health education

in grades kindergarten through twelfth grades. A comprehensive

health education curriculum provides teaching on personal

health/growth & development: nutrition: safety, first aid. and

injury prevention: environmental health: tobacco and other

substance use and abuse: consumer and community health: disease

prevention and control: mental and emotional health: and family

life and health. Community-based organizations can be important

resources for health education, particularly for working adults

and elderly citizens. A growing number of workplaces are offering

health education and health promotion activities for their

employees. Chapters of the American Association for Retired

Persons and agencies serving senior citizens have been

201

instrumental in getting the elderly involved in health education
initiatives.

PRESCRIPTION *3: Universal access to primary health care

We must aim at assuring for every American the clinical
preventive services that can prevent and provide early detection
and treatment of health problems. We need to expand
nontraditional approaches to health care delivery that increase
access for the hardest to reach and most vulnerable of our
citizens. There are many promising strategies underway in
America for reducing the gaps in primary health care. One
example in school-based clinics. Over 300 school-based clinics.
operating in 33 states, are now providing accessible, age-
appropriate, preventive and primary health care to children and
adolescents. (5)

To achieve universal access, health care reform will need to
successfully address many areas of concerns, such as the
inadequate supply and maldistribution of primary health care
providers and disproportionate rises in health care costs.

♦4.- Advancement of knowledge about the relationships between
environmental exposures and health

Tremendous gains in health status have been accomplished
during this century through public health efforts to assure
safe supplies of food and water, management of sewage and
municipal wastes, and elimination or control of illnesses borne
by. insects and other organisms. It is essential that these
efforts be sustained.

The greatest challenge for environmental health today is
advancing our Knowledge about the relationships between
environmental exposures and health problems. Population

BOSTON PUBLIC LIBRARY

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growth, urbanization, new energy sources, advanced technology,
industrialized and modern agricultural methods have created
dramatically different environmental health challenges. (2)

as. Support for our most important social environment. the
family.

It the job of families to provide the environment in which their

children and loved ones can be their healthiest and it the job of

government to support those af forts. There's a continuum of

family concerns which need governmental support: family planning .-

early childhood education: parenting education; male mentoring.-

college education.- in-home and community based systems of care

for persons with long term health needs and disabilities; and

hospice care. These concerns must be adequately addressed for our

children to be able to grow up healthy, motivated, and hopeful.

PRBSCRIPTIOH »6: Continued support for the Public Commissioned
Corps

The Surgeon General is responsible for tha administration and
management of the Commission Corps, a uniformed service of the
Public Health Service, consisting of health professionals in 11
different categories. The largest contingent, approximately 40
percent of the 6. 500 officers, are assigned to the Indian Health
Service where they provide health care to native Alaskans and
Americans, often in very remote and isolated areas of the
country. In addition, approximately 1.000 officers are detailed
to other Agencies such as the United States Coast Guard. Bureau
of Prisons. Environmental Protection Agency. Health Care
Financing Administration, and the District of Columbia Mental
Health Commission to provide health expertise.

203

All the officers play a critical role in protecting and. improving

the public's health. As a nation providing world leadership in

the area of public health it is important to have a unique.

respected corps of health professionals who have the credentials

which make them effective in relationships with the public, other

governmental agencies and representatives of foreign nations.

Continued support for the Commissioned Corpe is vital to the

Federal government's ability to respond to present and emerging

public health needs.

CONCLUSION

To protect and improve the health of every American, we must
learn about the conditions affecting our health status,
educate ourselves to the opportunities for improving our
health, and find the political will to obtain the resources
and implement the strategies that will maXe a difference in
all of our lives.

REFERENCES

1. United States Preventive Services Task Force, Guide — to
Clinical Preventive Services: An Assessment of the Effectiveness
of 169 Interventions, Report of the U.S. Preventive Services Task
Force. Williams & Wilkins. 1989.

2. United States Department of Health and Human Services.

Public Health Service. Haalthv People 2000= Hrtlffl+l tfealth

Promotion and Disease Prevention Objectives. 1990.

3. Institute of Medicine Committee for the Study of the Future
of Public Health, The Future of Public Health. National Academy
of Sciences Publication I0K; 88-02. 1988.

4. Partnership for Prevention. Today's Solution for Tomorrow's
Health. 426 C Street. N.E.. Washington. B.C. 20002.

5. Waszak. C. and Heidell. S. School -Beytd and School -I inked
Clinics: Update 1991- Center for Population Operation.
Washington. D.C., 1991.

204

ATTACHMENT B
RFNTTA I PROPERTY

HELD BY

M. JOYCELYN ELDERS, M.D.

as of 7/21/93 ~

Property Location

Date of Purchase

Current Mortgage Company

405 S. Pine, Utile Rock, AR

07/01/74

Ms. EN. Shivers, El Dorado

RL 4, Box 365G Elders Ct, Little Rock
("RL 4, House A" on Schedule A)

07/01/74

none

5417 Hders Ct, Little Rock, AR
("Rt 4, House B" on Schedule A)

07/01/74

none

3717 W. Capital, Utile Rock, AR

12/01/74

none

301 S. Oak, Uttle Rock, AR

01/01/76

1st Commercial Bank, LR

309 S. Oak, Uttle Rock, AR

10/01/77

1st Commercial Bank, L.R

5424 Hders Ct, Uttle Rock, AR
CRt 4, Trailer E" on Schedule A)

10/01/77

none

9325 Roundtop Dr., Uttle Rock, AR
("Rt 4, Trailer A" on Schedule A)

07/01/74

none

5407 Elders Ct, Uttle Rock, AR
(Tit 4, Trailer B" on Schedule A)

04/01/75

none

5412 Elders Ct, Uttle Rock, AR
("Rt 4, Trailer C on Schedule A)

04/01/76

none

5420 Elders Ct, Uttle Rock, AR
("Rt 4, Trailer F" on Schedule A)

01/01/74

none

4308 W. 11th, Uttle Rock, AR

05/01/82

none

4321 W. 11th, Uttle Rock, AR

08/01/82

none

4323 W.llth, Uttle Rock, AR

03/01/91

none

2621 Abigail, Uttle Rock, AR

07/01/82

none

2301 Cumberland, Uttle Rock, AR

06/01/82

none

3405 Lamar, Uttle Rock, AR

03/16/84

1st Commercial Bank, L.R

3417 Lamar, Uttle Rock, AR

03/16/84

Charter Mortgage, N.LR

3806 W. Capital Uttle Rock, AR

03/16/84

Charter Mortgage, N.L.R

306 & Schiller, Uttle Rock, AR

03/01/84

none

8906 & 8920 Morris Manor, Uttle Rock

03/01/86

1st Commercial Bank, L-R
Ms. Katheryn North, Havana

315 S. Maple, Uttle Rock, AR

07/01/79

none

516 - 518 S. Pine, Uttle Rock, AR

07/01/75

Superior Federal Savings, L.R

The Chairman. The committee stands in recess.
[Whereupon, at 4:54 p.m., the committee was adjourned.]

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Full text of "Nomination : hearing of the Committee on Labor and Human Resources, United States Senate, One Hundred Third Congress, first session, on M. Joycelyn Elders, of Arkansas, to be medical director ... Surgeon General of the Public Health Service, July 23, 1993"

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